The Romberg test: how it’s done and what a positive result means

Why closing your eyes matters

Standing still looks effortless, but your brain is blending three streams of information to do it: what your eyes see, what your inner ears sense about the position and movement of your head, and position sense, the constant report from the soles, ankles and joints about where your body is. Position sense travels in the largest, fastest sensory nerve fibers and then up the back of the spinal cord, in the dorsal columns.

Lose one stream and the other two usually cover for it. That is the idea behind the test. With the feet together, the base you stand on is narrow. Closing your eyes takes vision away. If position sense from the feet is also missing, the inner ear is left to do the job alone, and it can’t: the body starts to sway, then tips. Someone whose eyes are quietly doing the work can look completely normal in the exam room until they close them.

The same thing happens at home. The patients who tell us they walk fine in daylight but stagger to the bathroom at night, lose their balance in the shower when they close their eyes to rinse their hair, or wobble on grass and gravel are describing a positive Romberg, often long before anyone has tested for one.

How the Romberg test is done

1. Shoes off, on a firm, flat floor, with the area around you cleared and the examiner standing close beside or behind you.
2. Feet together, heels and big toes touching, with your arms by your sides or crossed over your chest.
3. Eyes open for about 30 seconds while the examiner watches how much you sway.
4. Eyes closed for 30 seconds to a minute. The examiner looks for a clear change: sway that keeps growing, a step to catch yourself, or a fall.

The examiner doesn’t hold you during the test but stays close enough to catch you. Nothing is measured with an instrument; the result is what the examiner sees.

Reading the result

The last row is the distinction most often missed. The Romberg test is commonly mistaken for a test of the cerebellum, but people with cerebellar problems tend to be unsteady with their eyes open too, so closing them changes less. The test is built to catch the person who is steady only while they can see.

It is also a blunt instrument. When researchers measured sway on a force plate in people with pure sensory neuropathy, sway roughly doubled with the eyes closed, but the patients also swayed more than healthy people with their eyes open, which shrinks the contrast the bedside test depends on, and the test separated patients from healthy people only modestly. That is why we read a Romberg result alongside the rest of the exam, never on its own.

What causes a positive Romberg

The nerves: large-fiber neuropathy

This is the cause we see most. When the large sensory fibers of the feet and legs are damaged, position sense and vibration sense fade together, usually with numbness that began in the toes. Causes include advanced diabetic neuropathy, chemotherapy (especially the platinum drugs), alcohol, inherited neuropathies such as Charcot–Marie–Tooth disease, and immune neuropathies such as CIDP. Large fiber neuropathy.

A smaller group damages the sensory nerve cells themselves, which sit in small clusters beside the spine. These sensory neuronopathies, seen with Sjögren’s syndrome, some cancers, platinum chemotherapy and very high doses of vitamin B6, can produce some of the most striking positive Romberg results, sometimes affecting the hands or face early rather than starting in the toes. Vitamin B6 toxicity.

The spinal cord: the dorsal columns

Position sense from the legs travels up the back of the spinal cord, so damage there gives the same result. Vitamin B12 deficiency is the classic cause, damaging the nerves and the cord together (subacute combined degeneration). Low B12 can follow years of metformin or acid-reducing medicines, a vegan diet without supplements, weight-loss or other stomach surgery, or pernicious anemia, and recreational nitrous oxide (“whippets”) can bring it on quickly by inactivating B12. Copper deficiency, often after stomach surgery, including weight-loss surgery, or from too much zinc, produces an almost identical picture. A narrowed spinal canal in the neck pressing on the cord, multiple sclerosis and, rarely now, late syphilis, the disease Romberg himself was describing, can do the same. Vitamin B12 and neuropathy.

The inner ear

When both inner ears have lost function, the eyes and feet carry the load, and closing the eyes can bring on the same sway and fall. In one large series of people with loss in both inner ears, the most common identifiable cause was a group of antibiotics (the aminoglycosides, such as gentamicin), followed by Ménière’s disease. These patients often have other clues: the world seems to bounce when they walk, or they have had attacks of vertigo or hearing changes. Standing with the eyes closed on a foam cushion leans harder on the inner ear, which is why balance clinics often add that version.

Balance problems that aren’t a Romberg sign

Problems with the cerebellum, from alcohol, a stroke or an inherited ataxia, Parkinson’s disease, weak legs, a drop in blood pressure on standing and medicines that cause drowsiness or dizziness all affect balance, usually with the eyes open as well. They matter just as much for falls, and a full balance exam looks for all of them.

The versions you may come across

• The sharpened (tandem) Romberg: heel to toe, as on a tightrope, with the eyes closed. It is harder and more sensitive, and is used in diving medicine to check divers after decompression illness. The ability to hold it with the eyes closed declines with age even in healthy adults, so the result is read against age norms.
• Romberg on foam: standing on a foam pad with the eyes closed, which tests the inner ear more than the feet.
• The single-leg stance: standing on one leg with the eyes open. In a University of Michigan study of older adults with neuropathy, those who had fallen in the past year could hold it for about 3 seconds on average, against about 9 seconds for those who hadn’t.
• The CDC 4-Stage Balance Test: four positions, each held for 10 seconds with the eyes open: feet side by side, the instep of one foot touching the big toe of the other, heel to toe, and one leg. An older adult who can’t hold the heel-to-toe stand for 10 seconds is at increased risk of falling.
• The modified Romberg used by some police officers: feet together, head tilted back and eyes closed while estimating when 30 seconds have passed. It isn’t one of the standardized field sobriety tests approved by the National Highway Traffic Safety Administration.

Checking your balance at home: never alone

Our view: if you want to check your balance at home, use the CDC’s 4-Stage Balance Test rather than the eyes-closed Romberg, and don’t do either alone. A positive Romberg means losing your balance, by definition.

• Stand in the corner of a room or with a sturdy counter in front of you, and have another adult right beside you, ready to hold you.
• Keep your eyes open, and move to the next position only if you held the last one for 10 seconds without moving your feet.
• Don’t test at all if you have fallen recently, feel dizzy or can’t stand without holding on. Tell your clinician instead.
• If you can’t hold the heel-to-toe stand for 10 seconds, or you sway sharply when you close your eyes with your feet together and someone beside you, book a balance assessment.

A positive Romberg with numb feet is a fall warning

The link between neuropathy and falls is not subtle. In the University of Michigan study, 55% of older adults with neuropathy confirmed by nerve testing had fallen in the previous year, against 10% of matched adults with normal nerves, and no other risk factor explained the difference. In a small study of younger adults with long-standing type 1 diabetes, those with neuropathy had about 15 times the odds of reporting an injury while walking. And in a large U.S. study of adults in their late seventies, neuropathy found with a simple monofilament test raised the risk of a fall or fracture by about half.

So when the Romberg is positive and the feet are numb, we don’t stop at naming the cause. We look at the shoes, the home, the medicines and the eyes, because vision is now doing a job the feet used to share.

If your Romberg is positive: what comes next

• The rest of the exam: vibration sense at the big toe with a tuning fork, position sense (with your eyes closed, can you tell whether your big toe is being moved up or down?), ankle reflexes, strength, and a monofilament test for protective sensation. Brisk reflexes alongside a positive Romberg point toward the spinal cord rather than the nerves.
• Blood tests: blood glucose, vitamin B12 with methylmalonic acid, and serum protein immunofixation, a test for abnormal blood proteins: the three the American Academy of Neurology rates highest-yield for neuropathy. Copper and zinc, and a vitamin B6 level if you take supplements, are added when the picture fits.
• Nerve testing: a nerve conduction study and EMG shows whether the large sensory fibers are damaged, and in what pattern.
• Imaging and other tests: MRI of the neck or spine when the cord is suspected, and inner ear testing when the story points there.

What helps

• Treat the cause, early. Vitamin B12 replacement stops B12-related spinal cord damage from progressing and improves it in most people, but full recovery is more likely when treatment starts before severe signs, a positive Romberg among them, have set in. Copper replacement halts copper-related damage, though recovery is often partial. Stopping excess vitamin B6 is the treatment for B6 toxicity.
• Train your balance. Exercise is one of the best-supported treatments for neuropathy. A 2022 review of 41 randomized trials found that exercise improved static balance and other balance and mobility measures in diabetic neuropathy, with balance (sensorimotor) training the key ingredient in chemotherapy neuropathy. A physical therapist can set a program hard enough to work and safe enough to do. Neuropathy exercises.
• Light the way. Night-lights from bed to bathroom, a light you can switch on before you stand up, and no walking in the dark.
• Make the bathroom safe. A grab bar and a shower chair; sit, or keep a hand on the bar, when you close your eyes to wash your hair.
• Wear real shoes, indoors too. Shoes with low heels and firm, slip-resistant soles are steadier than socks, slippers or bare feet, and walking indoors barefoot or in socks raises the risk of falling. Best shoes for neuropathy.
• Use support without embarrassment. A cane or walking poles, fitted by a physical therapist, add the point of contact the feet can no longer provide.
• Review your medicines and your eyes. Ask whether any of your medicines cause drowsiness or dizziness, and keep your glasses up to date: vision is now your backup sense.

Common questions

Related reading

Large fiber neuropathy · Vitamin B12 and neuropathy · Neuropathy exercises · The monofilament test · Nerve conduction study and EMG · Peripheral neuropathy symptoms · Best shoes for neuropathy