Romberg Test / Proprioception Exam Explained - Clinical Skills Deep Dive - Dr Gill

[Music] foreign hello and welcome back to the channel my name is Dr James Gill and you've joined us for another clinical skills video today we're going to be looking at the romberg's test which is used to look when we have sensory imbalances particularly an ataxic gate in terms of the romberg's test it was initially developed in the 1800s by uh Moritz Romberg essentially when he was assessing tabster saleus or neurosyphilis now with neurosyphilis the spirochetes have invaded the brain and will damage cerebellum and potentially the dorsal columns which are involved in proprioception it's very important because with the damage there we lose proprioception the knowledge of where your body is in space and thus we get an ataxic and imbalanced gait in order to maintain balance we need three components we need to have our vision systems intact we need to have our vestibular systems intact and we also need to have our proprioceptive systems intact so Vision allows us to focus on one point to ensure we are not moving the vestibular system essentially allows us to tell which way is down and thus improve our balance and our proprioception systems allows us to determine where on joints and muscles are positioned so where our body is we can maintain adequate balance with one of those systems impaired however if two systems are impaired then that will produce a an issue I.E a positive rhombox test so in terms of demonstrating the romberg's test my name is Dr James Gill I've been asked to do an examination of your balance today that'd be okay yep so before we go any further can we please confirm your name and date of birth photographs I'll be 2nd January 2000. so what we're going to do we're going to get you to do a short walk which will allow us to assess your gate we assume that it's going to be normal but we'll still continue on with the examination then we're going to get you to stand and focus on something against the wall and we'll see what happens with your balance if anything and then we're going to do the same again with a slight change in your stance but with your eyes closed is that okay super Pacific walk forwards for it so at this stage we're observing the patient as they're walking and confirming that in this particular situation there is no obvious ataxic gait so we wouldn't need to proceed forward but for the system for the examination here we will do so so we want to have you stand with your feet shoulder width apart and the examination can be performed with the patient's Arms by their side or crossed over the chest I like to have it crossed over the chest because it's providing some distraction to the patient rather than their arms hanging and if you could look forward for 30 seconds as we do so we're observing to see if there is any abnormalities in terms of sway as the patient is standing there it's not uncommon even in healthy individuals to have a very slight sway at this point however if we did have a problem with the proprioception or the vestibular system at this point then we might expect the patient to have difficulty holding this position and perhaps they would move their legs or certainly be swaying much more considerably with our 30 seconds elapsed we've seen no issues here we're going to increase the difficulty now so the next part of the examination we're going to stay with your feet shoulder width apart and your arms over your chest but I'm going to stand with my arms either side of you this is to make sure that you don't fall if there's any problems I'll tap you to one shoulder or the other or stop you moving overall so with that in mind do you feel safe to continue okay so if you close your eyes please and we're going to see if there's any swaying at all so he's down there so at this point in terms of our Triad we have at a healthy patient we have proprioception intact and we have the vestibular system intact but we have removed Vision so we're going to get a slight sway here is exceptionally minor but it has increased somewhat as we'd expect for a normal individual however if we had somebody where either the vestibular system or the proprioceptive system was impaired at this point we might expect to see significant sway or perhaps the need to move out of the stance over those 30 seconds so we've seen no abnormalities here so if you open your eyes it's very important when you're doing this assessment you're either standing right next to Patient or as my preference you have your arms out and the patient is aware of that so they have the confidence in allowing you to safely ask them to perform this examination there is a third step if required with regard to romberg's called a a tandem gate or a sharpening of the romberg's test this is specific to decompression injuries in divers so isn't used that frequently what we'd ask you to do is move one foot behind the other so your toes are touching your heel would do the same again Cross Your Arms over your chest and again I'll make sure you don't fall and if you close your eyes so right away as I'm observing here we've got a slight shake or shimmy coming on because this is a much more difficult test even in a healthy individual but a healthy individual with Mod mild to moderate sway should be able to complete the test if however the patient stepped out of alignment or the sway was sufficient I would terminate the test then that would be considered to be a positive Romberg sign okay and open your eyes super so there were no abnormalities there and you successfully passed the test so we've confirmed that there's no obvious issues with your vestibular visual or proprioceptive systems do you have any questions myself no super thank you now I get a lot of requests to do sponsors and shout outs on the channel and I've always said no so far because actually none of the products that I thought were appropriate and I don't want to talk about a random thing as far as I'm concerned however I've recently been contacted by blinkist who are running an offer at the moment and I said yes the reason why I've said yes to blinkers is I use it all the time if you've not heard of it blinkist is essentially a way of getting the knowledge out of books if you're compressed for time which is something I struggle with all the while it's useful to for me to be able to say to patients if they're struggling with sleep this is a difficult subject for you you know have a listen to this on blinkist it's just 15 minutes if you find that you've been interested in this maybe go and read the whole book and that'll give you a lot of information about well the science of how we sleep and using that I find is a really good way of deciding if I actually want to you know listen to a whole book so it's kind of like knowledge compressed so blinkist have said hey would I like to do a shout out and because I use this and have done for quite some time yes I wouldn't here it is as a result of that conversation with blinkist they've highlighted that they're doing a new premium uh subscription which actually doesn't cost any more than their regular subscription basically means that you can have two people using the account so myself and my new wife I can both sort of access these um you know books as we're out and about as we're driving to clinics and things so if that sounds of interest to yourself I would definitely recommend having a look at it um there's the logo here and there's a code in the description which will get you 25 off um yeah back to the wrong books test so in terms of what conditions would we see a positive Romberg sign we may see in Meniere's disease where the vestibular cochlear system has been affected we may see it in B12 deficiency where we may have had some acute combined degeneration of the cord we may have problems where we've got posterior spinal syndrome where there's been an infarction to one of the posterior spinal arteries again affecting the nerves back there we could have as mentioned have neurosyphilis or tabster cellulose specifically affecting the dorsal columns we may also have slightly more esoteric conditions causing a positive Romberg sign for example peripheral neuropathy which we may see in advanced diabetes here the problem isn't so much with the transmission of the signal down the dorsal columns but actually the generation of the signal from the peripheral nervous system in the first place and as a result of this that's one of the reasons we're going to strive greatly to reduce the probability of peripheral neuropathy in diabetes because the global impact this disease can have so balance is comprised of three features we have our visual system we have our vestibular system and we have our proprioceptive system if we lose one of those three features then balance will be remained intact however if we lose two of those systems then bounce will be impaired the romberg's test is assessing the vestibular and the proprioceptive systems if we ask the patient to close their eyes during the romberg's test we're limited just to the vestibular system and the proprioceptive system to maintain balance if one of those two systems is also impaired then we'll see the patient step or sway significantly during the romberg's test we would however need to go on further in order to diagnose whether or not it is a proprioceptive issue or a vestibular issue that of course rise to a positive rhombocs there is a variation of the romberg's test where the patient is asked to stand on a block of foam this tends to be only done in neurology clinics and isn't something that's widely available by standing on the block of foam it removes or dampens the proprioceptive responses from the body and gives much a more effective test with regard to identifying if we have a vestibular issue or a proprioceptive issue when the patient stands on the block of foam because they it's diminishing the proprioceptive input if they're then losing their balance we know the vestibular system is the impaired one as their eyes are still open at that point well I hope this has been a useful video for yourselves please like the video If so because it tells YouTube we're here please put any questions and things in the comments and we'll see if we can help you out with those if you'd like to subscribe to the channel it allows you to know when the next videos are coming but more importantly engage with us in the communities tab or you can help us plan further videos thank you take care