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<br>
== Introduction  ==
</div>
[[File:Romberg.jpg|alt=|thumb|257x257px|Romberg test]]
== Introduction<br> ==
The Romberg test is a test that measures a person's sense of [[balance]]. Specifically, the test assesses the function of the [[Dorsal Column Medial Lemniscal Pathway|dorsal column]] of the [[Spinal cord anatomy|spinal cord]] (the dorsal column is responsible for [[proprioception]]).<ref>Healthline Romberg test Available:https://www.healthline.com/health/romberg-test#What-is-Rombergs-test? (accessed 6.11.2022)</ref>


The Romberg test is an appropriate tool to diagnose sensory ataxia, a gait disturbance caused by abnormal proprioception involving information about the location of the joints. It is also proven to be sensitive and accurate means of measuring the degree of disequilibrium caused by the central vertigo, peripheral vertigo and head trauma.&nbsp;<ref name="soochan">Soochan Kim, Mijoo Kim, Nambom Kim, Sungmin Kim, Gyucheol Han.Quantification and Validity of Modified Romberg Tests Using Three-Axis Accelerometers.Green and Smart Technology with Sensor Applications. Communications in Computer and Information Science Volume 338, 2012, pp 254-261.</ref>&nbsp;It has been used in clinic for 150 years <ref name="reicke">Reicke, N.: The Romberg head-shake test within the scope of equilibrium diagnosis. H.N.O 40, 195–201 (1992)</ref>&nbsp;
The Romberg test is an appropriate tool to diagnose sensory [[ataxia]] (a gait disturbance caused by abnormal proprioception involving information about the location of the joints). Examples of conditions include: Subacute combined degeneration of the spinal cord ([[Vitamin B12 Deficiency|Vitamin B12 deficiency]]); Posterior cord syndrome (Posterior spinal artery infarction); Hemi-section of spinal cord ([[Brown-Sequard Syndrome|Brown Sequard syndrome]])<ref name=":0">Epomedicine Romberg test Available:https://epomedicine.com/clinical-medicine/romberg-test/ (accessed 6.11.2022)</ref>


== Purpose<br> ==
It is also proven to be a sensitive and accurate means of measuring the degree of disequilibrium caused by central [[vertigo]], peripheral vertigo, and [[Traumatic Brain Injury|head trauma]].<ref name="soochan">Soochan Kim, Mijoo Kim, Nambom Kim, Sungmin Kim, Gyucheol Han.Quantification and Validity of Modified Romberg Tests Using Three-Axis Accelerometers.Green and Smart Technology with Sensor Applications. Communications in Computer and Information Science Volume 338, 2012, pp 254-261.</ref> It has been used in clinic for 150 years <ref name="reicke">Reicke, N.: The Romberg head-shake test within the scope of equilibrium diagnosis. H.N.O 40, 195–201 (1992)</ref>  


The Romberg test is used to demonstrate the effects of posterior column disease upon human upright postural control. Posterior column disease involves selective damaging of the posterior column, known as tabes dorsalis neurosyphilis. The Romberg test is used for the clinical assessment of patients with disequilibrium or ataxia from sensory and motor disorders.  
== Purpose  ==
The Romberg Test assesses the function of the [[Dorsal Column Medial Lemniscal Pathway]], the neural pathways by which sensory information from the peripheral nerves is transmitted to the [[Cerebral Cortex|cerebral cortex]].  


Equilibrium is defined as any condition in which all acting forces are cancelled by each other resulting in a stable balanced system. It is maintained through the sensory information from vestibular, somatosensory and visual systems.&nbsp;A patient who has a problem with [[Proprioception]]&nbsp;(Somato sensory) can still maintain balance by compensating with vestibular function and vision. In the Romberg test, the patient stands upright and asked to close his eyes. A loss of balance is interpreted as a positive Romberg sign.
# When the person is standing with the eyes open, visual, proprioceptive, and [[Vestibular System|vestibular]] information is used to maintain postural stability.
 
# When the eyes are closed, the patient must rely on proprioception and [[Vestibular Assessment|vestibular function.]]<ref name=":0" />
The Romberg test was first described in 1846 and was originally described for the condition tabes dorsalis. Before performing the Romberg test, it is necessary to test other aspects of the patient's balance when potential issues with ataxia or disequilibrium are present. Often, proprioceptive challenges are not the first problems faced by this population. Sometimes, it is more simple. It is important to first assess other aspects of balance impairment in order to rule out confounding factors that could lead to a false positive test<ref name="Goebel">Goebel JA. Practical management of the dizzy patient. Philadelphia: Lippincott Williams &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Wilkins, 2008.</ref><ref name="Black">Black FO, et al. Normal subject postural sway during the Romberg test. Am J Otolaryngol. 1982 Sep-Oct;3(5):309-18.</ref>.
 
== Clinically Relevant Anatomy<br> ==
 
There are three sensory systems that provide input to the cerebellum to maintain truncal stability when the eyes are open:


== Clinically Relevant Anatomy  ==
Three sensory systems provide input to the cerebellum to maintain truncal stability when the eyes are open:
#Vision  
#Vision  
#[[Proprioception|Proprioception]]  
#[[Proprioception|Proprioception]]  
#Vestibular sense.
#Vestibular sense
 
Only two of the three systems are needed to maintain balance.


Only two of the three systems are needed to maintain balance. When visual input is removed, instability due to lack of vision can be teased apart from other sensory impairments. If there is a more severe proprioceptive or vestibular lesion, or if there is a midline cerebellar lesion causing truncal instability, the patient will be unable to maintain the standing position, even when the eyes are open. Note that instability can also be seen with lesions in other parts of the nervous system, such as the upper or lower motor neurons, or the basal ganglia<ref name="Blumenfeld">Blumenfeld, H. Neuroexam.com - Romberg test. www.neuroexam.com/neuroexam/content.php?p=37 (accessed 31 Dec 2013).</ref><ref name="Zelczak">Zelczak TA. Neurologic examination. www.pacificu.edu/optometry/ce/courses/15840/neuroexampg3.cfm (accessed 31 Dec 2013).</ref>.  
* When visual input is removed, instability due to lack of vision can be teased apart from other sensory impairments.
* If there is a more severe proprioceptive or vestibular lesion, or if there is a midline [[Cerebellar Ataxia - A Case Study|cerebellar]] lesion causing truncal instability, the patient will be unable to maintain the standing position, even when the eyes are open.
* Note that instability can also be seen with lesions in other parts of the nervous system, such as the upper or lower motor neurons, or the [[Basal Ganglia|basal ganglia]]<ref name="Blumenfeld">Blumenfeld, H. Neuroexam.com - Romberg test. www.neuroexam.com/neuroexam/content.php?p=37 (accessed 31 Dec 2013).</ref><ref name="Zelczak">Zelczak TA. Neurologic examination. www.pacificu.edu/optometry/ce/courses/15840/neuroexampg3.cfm (accessed 31 Dec 2013).</ref>.  


== Technique<br> ==
== Technique ==


=== The Original Romberg test  ===
=== The Original Romberg test  ===


The test is performed as follows:  
The test is performed as follows:  
#The patient is asked to remove his shoes and stand with his two feet together. The arms are held next to the body or crossed in front of the body.  
#The patient is asked to remove his shoes and stand with his two feet together. The arms are held next to the body or crossed in front of the body.  
#The clinician asks the patient to first stand quietly with eyes open, and subsequently with eyes closed. The patient tries to maintain his balance. For safety, it is essential that the observer stand close to the patient to prevent potential injury if the patient were to fall. When the patients closes his eyes, he should not orient himself by light, sense or sound, as this could influence the test result and cause a false positive outcome.  
#The clinician asks the patient to first stand quietly with eyes open, and subsequently with eyes closed. The patient tries to maintain his balance. For safety, the observer must stand close to the patient to prevent potential injury if the patient were to fall. When the patient closes his eyes, he should not orient himself by light, sense, or sound, as this could influence the test result and cause a false positive outcome.
#The Romberg test is scored by counting the seconds the patient is able to stand with eyes closed.
#The Romberg test is scored by counting the seconds the patient can stand with eyes closed.
 
*The literature does not report alternative methods for scoring a Romberg test.
<br>
*To make the Romberg test more difficult, the clinician can attempt to disturb the patient's balance with a perturbation. The clinician mustn't exaggerate the perturbation.
 
*A Romberg test can also be used as a follow-up assessment for patients with balance and/or proprioception impairments by comparing several different assessments with each other.
[[Image:Romberg.jpg|153x257px]]
*If the clinician observes that the patient can stand for longer periods with the eyes closed, it is evident that the patient's balance and proprioceptive deficits have improved<ref name="Goebel">Goebel JA. Practical management of the dizzy patient. Philadelphia: Lippincott Williams &amp; Wilkins, 2008.</ref><ref name="Johnson">Johnson BG, et al. The sharpened Romberg test for assessing ataxia in mild acute mountain sickness. Wilderness Environ Med. 2005 Summer;16(2):62-6.</ref><ref name="Black">Black FO, et al. Normal subject postural sway during the Romberg test. Am J Otolaryngol. 1982 Sep-Oct;3(5):309-18.</ref><ref name="Brinkman">Brinkman DMC, et al. Kwantificering en evaluatie van 5 neurologische evenwichtstests bij proefpersonen en patiënten. Ned Tijdschr Geneeskd. 1996;140:2176-80.</ref>.
 
*The Romberg test is positive when the patient is unable to maintain balance with their eyes closed. Losing balance can be defined as increased body sway, placing one foot in the direction of the fall, or even falling.<br>
*The literature does not report alternative methods for scoring a Romberg test.<br>
{{#ev:youtube|YBQNwvWgREU|300}}
*<span>&nbsp;</span>To make the Romberg test more difficult, the clinician can attempt to disturb the patient's balance with a perturbation. It is important that the clinician does not exaggerate the perturbation.  
*A Romberg test can also be used as follow-up assessment for patients with balance and/or proprioception impairments by comparing several different assessments with each other.  
*If the clinician observes that the patient is able to stand for longer periods of time with the eyes closed, it is evident that the patient's balance and proprioceptive deficits have decreased<ref name="Goebel" /><ref name="Johnson">Johnson BG, et al. The sharpened Romberg test for assessing ataxia in mild acute mountain sickness. Wilderness Environ Med. 2005 Summer;16(2):62-6.</ref><ref name="Black" /><ref name="Brinkman">Brinkman DMC, et al. Kwantificering en evaluatie van 5 neurologische evenwichtstests bij proefpersonen en patiënten. Ned Tijdschr Geneeskd. 1996;140:2176-80.</ref>.  
*The Romberg test is positive when the patient is unable to maintain balance with their eyes closed. Losing balance can be defined as increased body sway, placing one foot in the direction of the fall, or even falling.
 
<br>
 
{{#ev:youtube|YBQNwvWgREU|300}}  
 
<br>


=== The Sharpened or Tandem Romberg test  ===
=== The Sharpened or Tandem Romberg test  ===
[[File:Romberg_2.jpg|alt=|right|564x564px]]
The Sharpened or Tandem Romberg test is a variation of the original test. The implementation is mostly the same. 


The Sharpened or Tandem Romberg test is a variation of the original test. The implementation is mostly the same. For this second test, the patient has to place his feet in heel-to-toe position, with one foot directly in front of the other. As with the original Romberg test, the assessment is performed first with eyes open and then with eyes closed. The patient crosses his arms over his chest, and the open palm of the hand lies on the opposite shoulder. The patient also distributes his weight over both his feet and holds his chin parallel with the floor<ref name="Johnson" /><ref name="Black" />. <br>
* For this second test, the patient has to place his feet in a heel-to-toe position, with one foot directly in front of the other.
 
* As with the original Romberg test, the assessment is performed first with eyes open and then with eyes closed.  
[[Image:Romberg 2.jpg|369x196px]]  
* The patient crosses his arms over his chest, and the open palm lies on the opposite shoulder. The patient also distributes his weight over both his feet and holds his chin parallel to the floor<ref name="Johnson" /><ref name="Black" />.
 
* [[Obesity|Obese]] and older individuals may be unable to stand in this position for prolonged periods. For these populations, the Romberg test does not exclusively demonstrate proprioceptive impairments in comparison to other confounding factors<ref name="Goebel" />.<br>  
Obese and older individuals may be unable to stand in this position for prolonged periods of time. For these populations, the Romberg test does not exclusively demonstrate propropioceptive impairments in comparison to other confounding factors<ref name="Goebel" />.<br>


{{#ev:youtube|NS6XtWFbqjc|300}}  
{{#ev:youtube|NS6XtWFbqjc|300}}  


== Variables<br> ==
== Variables ==
 
Although a patient with an acute peripheral vestibular lesion is usually inclined to move towards the side of the problem, it has been shown that chronic vestibular damage (at least partial compensation) does not produce deficits in the standard Romberg test. Also, an individual with proprioceptive problems, accessory to tabes dorsalis, would be unable to stand with the eyes closed and feet together<ref name="Goebel" />.  
Although a patient with an acute peripheral vestibular lesion is usually inclined to move towards the side of the problem, it has been shown that chronic vestibular damage (at least partial compensation) does not produce deficits in the standard Romberg test. As well, an individual with proprioceptive problems, accessory to tabes dorsalis, would be unable to stand with the eyes closed and feet together<ref name="Goebel" />.  


Many believe that the sharpened Romberg test is a better indicator of vestibular impairment than the original Romberg test. The sharpened Romberg test results give an objective measure of postural stability. This can help to quantify ataxia<ref name="Goebel" />.  
Many believe that the sharpened Romberg test is a better indicator of vestibular impairment than the original Romberg test. The sharpened Romberg test results give an objective measure of postural stability. This can help to quantify ataxia<ref name="Goebel" />.  
Line 72: Line 64:
Subject, sex, and age do not create a statistically significant difference between normal subjects between the ages of 20 and 49 years; only the Romberg sharpened test with eyes open provided a significant difference (p&lt; 0.05) between men and women. Greater instability in subjects less than 20 and more than 50 years of age was also exhibited. When comparing a young and an old cohort, there is a significant difference in performance.  
Subject, sex, and age do not create a statistically significant difference between normal subjects between the ages of 20 and 49 years; only the Romberg sharpened test with eyes open provided a significant difference (p&lt; 0.05) between men and women. Greater instability in subjects less than 20 and more than 50 years of age was also exhibited. When comparing a young and an old cohort, there is a significant difference in performance.  


Increasing the difficulty of the tandem Romberg test for patients is not helpful because it also makes the tests more difficult to perform for controls with no symptoms of vestibular disease. This would also make it harder to evaluate the test results. Decreased performance times on the modified Romberg is associated with a concomitant rise in the risk of falling<ref name="Black" /><ref name="Longridge">Longridge NS. Clinical romberg testing does not detect vestibular disease. Otol Neurotol. 2010 Jul;31(5):803-6.</ref><ref name="Agrawal">Agrawal Y. The modified Romberg balance test: normative data in US adults. Otol Neurotol, 2011 Oct,32(8):1309–1311.</ref>.&nbsp;  
Increasing the difficulty of the tandem Romberg test for patients is not helpful because it also makes the tests more difficult to perform for controls with no symptoms of vestibular disease. This would also make it harder to evaluate the test results. Decreased performance times on the modified Romberg are associated with a concomitant rise in the risk of falling<ref name="Black" /><ref name="Longridge">Longridge NS. Clinical Romberg testing does not detect vestibular disease. Otol Neurotol. 2010 Jul;31(5):803-6.</ref><ref name="Agrawal">Agrawal Y. The modified Romberg balance test: normative data in US adults. Otol Neurotol, 2011 Oct,32(8):1309–1311.</ref>.&nbsp;<br>  
 
<br>


== Reliability and Validity  ==
== Reliability and Validity  ==


There is no consensus in the Reliability (Intra and inter) and validity for romberg's in the literature as the test is more of qualitative rather than quantitative(Objective) . However, this test can be used as a quick clinical tool to screen . The introduction of various instrument in the arena of balance assessment and the force plat form usage has given the more objective and accurate measurement.&nbsp;  
There is no consensus in the Reliability (Intra and inter) and validity for Romberg's in the literature as the test is more of qualitative rather than quantitative (Objective). However, this test can be used as a quick clinical tool to screen. The introduction of various instrument in the arena of balance assessment and the force platform usage has given the more objective and accurate measurement.&nbsp;<br>  
 
<br>
 
== Limitations<ref name="Mcmicheal">McMichael,K.A., Vander, B.J., Lavery, L., Rodriguez, E., Ganguli, M.: Simple balance and mobility tests can assess falls risk when cognition is impaired. Geriatr. Nurs. 29, 311–323 (2008)</ref>&nbsp;<ref name="o neil">O’Neil, D.E., Gill-Body, K.M., Krebs, D.E.: Posturography changes do not predict functional performance changes. Am J. Otol. 19, 797–803 (1998)</ref>  ==


== Limitations==
*Not Quantitative  
*Not Quantitative  
*Low diagnostic sensitivity and specificity  
*Low diagnostic sensitivity and specificity  
*Low power to determine lesions, predict the risk of falling amd reflect the discomfortand ability to perform daily activities.&nbsp;
*Low power to determine lesions, predict the risk of falling, and reflect the discomfort and ability to perform daily activities.<ref name="Mcmicheal">McMichael,K.A., Vander, B.J., Lavery, L., Rodriguez, E., Ganguli, M.: Simple balance and mobility tests can assess falls risk when cognition is impaired. Geriatr. Nurs. 29, 311–323 (2008)</ref><ref name="o neil">O’Neil, D.E., Gill-Body, K.M., Krebs, D.E.: Posturography changes do not predict functional performance changes. Am J. Otol. 19, 797–803 (1998)</ref>
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
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== References<br> ==


<references /><br>
== References  ==
<references />


[[Category:Special_Tests]] [[Category:Outcome_Measures]] [[Category:Assessment]] [[Category:Neurology]] [[Category:Falls]]
[[Category:Special_Tests]]  
[[Category:Outcome_Measures]]  
[[Category:Assessment]]  
[[Category:Balance - Special Tests]]
[[Category:Neurology]]  
[[Category:Falls]]
[[Category:Neurological - Outcome Measures]]
[[Category:Rehabilitation Foundations]]
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[[Category:Vestibular - Assessment and Examination]]
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Latest revision as of 01:59, 29 February 2024

Introduction[edit | edit source]

Romberg test

The Romberg test is a test that measures a person's sense of balance. Specifically, the test assesses the function of the dorsal column of the spinal cord (the dorsal column is responsible for proprioception).[1]

The Romberg test is an appropriate tool to diagnose sensory ataxia (a gait disturbance caused by abnormal proprioception involving information about the location of the joints). Examples of conditions include: Subacute combined degeneration of the spinal cord (Vitamin B12 deficiency); Posterior cord syndrome (Posterior spinal artery infarction); Hemi-section of spinal cord (Brown Sequard syndrome)[2]

It is also proven to be a sensitive and accurate means of measuring the degree of disequilibrium caused by central vertigo, peripheral vertigo, and head trauma.[3] It has been used in clinic for 150 years [4]

Purpose[edit | edit source]

The Romberg Test assesses the function of the Dorsal Column Medial Lemniscal Pathway, the neural pathways by which sensory information from the peripheral nerves is transmitted to the cerebral cortex.

  1. When the person is standing with the eyes open, visual, proprioceptive, and vestibular information is used to maintain postural stability.
  2. When the eyes are closed, the patient must rely on proprioception and vestibular function.[2]

Clinically Relevant Anatomy[edit | edit source]

Three sensory systems provide input to the cerebellum to maintain truncal stability when the eyes are open:

  1. Vision
  2. Proprioception
  3. Vestibular sense

Only two of the three systems are needed to maintain balance.

  • When visual input is removed, instability due to lack of vision can be teased apart from other sensory impairments.
  • If there is a more severe proprioceptive or vestibular lesion, or if there is a midline cerebellar lesion causing truncal instability, the patient will be unable to maintain the standing position, even when the eyes are open.
  • Note that instability can also be seen with lesions in other parts of the nervous system, such as the upper or lower motor neurons, or the basal ganglia[5][6].

Technique[edit | edit source]

The Original Romberg test[edit | edit source]

The test is performed as follows:

  1. The patient is asked to remove his shoes and stand with his two feet together. The arms are held next to the body or crossed in front of the body.
  2. The clinician asks the patient to first stand quietly with eyes open, and subsequently with eyes closed. The patient tries to maintain his balance. For safety, the observer must stand close to the patient to prevent potential injury if the patient were to fall. When the patient closes his eyes, he should not orient himself by light, sense, or sound, as this could influence the test result and cause a false positive outcome.
  3. The Romberg test is scored by counting the seconds the patient can stand with eyes closed.
  • The literature does not report alternative methods for scoring a Romberg test.
  • To make the Romberg test more difficult, the clinician can attempt to disturb the patient's balance with a perturbation. The clinician mustn't exaggerate the perturbation.
  • A Romberg test can also be used as a follow-up assessment for patients with balance and/or proprioception impairments by comparing several different assessments with each other.
  • If the clinician observes that the patient can stand for longer periods with the eyes closed, it is evident that the patient's balance and proprioceptive deficits have improved[7][8][9][10].
  • The Romberg test is positive when the patient is unable to maintain balance with their eyes closed. Losing balance can be defined as increased body sway, placing one foot in the direction of the fall, or even falling.

The Sharpened or Tandem Romberg test[edit | edit source]

The Sharpened or Tandem Romberg test is a variation of the original test. The implementation is mostly the same.

  • For this second test, the patient has to place his feet in a heel-to-toe position, with one foot directly in front of the other.
  • As with the original Romberg test, the assessment is performed first with eyes open and then with eyes closed.
  • The patient crosses his arms over his chest, and the open palm lies on the opposite shoulder. The patient also distributes his weight over both his feet and holds his chin parallel to the floor[8][9].
  • Obese and older individuals may be unable to stand in this position for prolonged periods. For these populations, the Romberg test does not exclusively demonstrate proprioceptive impairments in comparison to other confounding factors[7].

Variables[edit | edit source]

Although a patient with an acute peripheral vestibular lesion is usually inclined to move towards the side of the problem, it has been shown that chronic vestibular damage (at least partial compensation) does not produce deficits in the standard Romberg test. Also, an individual with proprioceptive problems, accessory to tabes dorsalis, would be unable to stand with the eyes closed and feet together[7].

Many believe that the sharpened Romberg test is a better indicator of vestibular impairment than the original Romberg test. The sharpened Romberg test results give an objective measure of postural stability. This can help to quantify ataxia[7].

Subject, sex, and age do not create a statistically significant difference between normal subjects between the ages of 20 and 49 years; only the Romberg sharpened test with eyes open provided a significant difference (p< 0.05) between men and women. Greater instability in subjects less than 20 and more than 50 years of age was also exhibited. When comparing a young and an old cohort, there is a significant difference in performance.

Increasing the difficulty of the tandem Romberg test for patients is not helpful because it also makes the tests more difficult to perform for controls with no symptoms of vestibular disease. This would also make it harder to evaluate the test results. Decreased performance times on the modified Romberg are associated with a concomitant rise in the risk of falling[9][11][12]

Reliability and Validity[edit | edit source]

There is no consensus in the Reliability (Intra and inter) and validity for Romberg's in the literature as the test is more of qualitative rather than quantitative (Objective). However, this test can be used as a quick clinical tool to screen. The introduction of various instrument in the arena of balance assessment and the force platform usage has given the more objective and accurate measurement. 

Limitations[edit | edit source]

  • Not Quantitative
  • Low diagnostic sensitivity and specificity
  • Low power to determine lesions, predict the risk of falling, and reflect the discomfort and ability to perform daily activities.[13][14]

References[edit | edit source]

  1. Healthline Romberg test Available:https://www.healthline.com/health/romberg-test#What-is-Rombergs-test? (accessed 6.11.2022)
  2. 2.0 2.1 Epomedicine Romberg test Available:https://epomedicine.com/clinical-medicine/romberg-test/ (accessed 6.11.2022)
  3. Soochan Kim, Mijoo Kim, Nambom Kim, Sungmin Kim, Gyucheol Han.Quantification and Validity of Modified Romberg Tests Using Three-Axis Accelerometers.Green and Smart Technology with Sensor Applications. Communications in Computer and Information Science Volume 338, 2012, pp 254-261.
  4. Reicke, N.: The Romberg head-shake test within the scope of equilibrium diagnosis. H.N.O 40, 195–201 (1992)
  5. Blumenfeld, H. Neuroexam.com - Romberg test. www.neuroexam.com/neuroexam/content.php?p=37 (accessed 31 Dec 2013).
  6. Zelczak TA. Neurologic examination. www.pacificu.edu/optometry/ce/courses/15840/neuroexampg3.cfm (accessed 31 Dec 2013).
  7. 7.0 7.1 7.2 7.3 Goebel JA. Practical management of the dizzy patient. Philadelphia: Lippincott Williams & Wilkins, 2008.
  8. 8.0 8.1 Johnson BG, et al. The sharpened Romberg test for assessing ataxia in mild acute mountain sickness. Wilderness Environ Med. 2005 Summer;16(2):62-6.
  9. 9.0 9.1 9.2 Black FO, et al. Normal subject postural sway during the Romberg test. Am J Otolaryngol. 1982 Sep-Oct;3(5):309-18.
  10. Brinkman DMC, et al. Kwantificering en evaluatie van 5 neurologische evenwichtstests bij proefpersonen en patiënten. Ned Tijdschr Geneeskd. 1996;140:2176-80.
  11. Longridge NS. Clinical Romberg testing does not detect vestibular disease. Otol Neurotol. 2010 Jul;31(5):803-6.
  12. Agrawal Y. The modified Romberg balance test: normative data in US adults. Otol Neurotol, 2011 Oct,32(8):1309–1311.
  13. McMichael,K.A., Vander, B.J., Lavery, L., Rodriguez, E., Ganguli, M.: Simple balance and mobility tests can assess falls risk when cognition is impaired. Geriatr. Nurs. 29, 311–323 (2008)
  14. O’Neil, D.E., Gill-Body, K.M., Krebs, D.E.: Posturography changes do not predict functional performance changes. Am J. Otol. 19, 797–803 (1998)