56yo pt has been dx with MS. She presents with a positive Romberg’s test

A	56yo	pt	has	been	dx	with	MS.	She	presents	with	a	positive	Romberg’s	test.	She	also	has	weakness	and	loss	of	sensations	in	all	her	4	limbs.	Which	site	is	most	likely	to	be	affected?	

a. Cerebral cortex
b. Cerebellum
c. Cervical spinal cord
d. Thoracic spinal cord
e. Brain stem

Clincher(s) In positive Romberg sign Proprioception and vestibular apparatus are involved , A B From GP note book Romberg’s sign is positive if the patient requires vision to stand steadily.

The patient is asked to stand with the feet together. If the patient is steady with eyes open but unsteady with eyes closed then there are signs of Rombergism.

Romberg’s sign is said to be positive in patients with sensory ataxia and negative in cerebellar ataxia. Then it is sensory ataxia. Ask to close his eyes, loose his balance: then it’s positive and this excludes cerebellar ataxia.

In practise Romberg’s sign has a low specificity.

In cerebellar disease, the patient is often unsteady with the eyes open or closed.

KEY c. Cervical spinal cord Additional Information Taken from USMLE FORUM •Romberg test is only positive if the patient has intact balance with eyes OPEN but impaired balance with eyes CLOSED. If the patient has trouble with eyes OPEN (and, by extension, he will surely have impaired balance with eyes closed also), it is not a positive romberg test and that is probably more indicative of cerebellar etiology. The reason Romberg is a proprioceptive test is because it only applies when the patient has a discrepancy regarding balance with eyes open and with eyes closed. An easy way to justify this is you need 2 out of the 3 systems working at any given time to maintain balance.

If your eyes are closed, those are out, and if you have impaired proprioception, that’s out, thus you are only relying on cerebellum and will have impaired balance (positive romberg).

If your eyes are open, and you still have trouble with balance, what does that mean? (If you can answer this, then I think you understand my horrible explanation) so To maintain gait, you need: (a) positional sense (comes from visual, vestibular, and proprioceptive input) (b) motor output (both corticospinal tract and basal ganglia) © integration of senses (a) with motor output (b) (cerebellum) RABIA notes : Romberg’s Test is used to identify instability of either peripheral or central cause - The patient stands up straight with feet together (or at a distance for them to be steady) with arms outstretched. Then ask them to shut their eyes. • If they are unable to maintain their balance with their eyes closed, the test is positive (usually fall to the side of the lesion so stay close by to prevent them falling). • A positive test suggests a problem with proprioception or vestibular function. Romberg’s test can also be positive in neuromuscular disorders and may not be reliable in very elderly people. Multiple sclerosis causes demyelination of neurons in brain and spinal cord leading to neurological symptoms and loss of sensation, difficulty in movement, coordination and balance. In this case, all limbs are affected, so the level of lesion will be higher, ie. cervical spine. Positive Romberg sign is 90% sensitive for lumbar spinal stenosis Wikipedia: “Proprioception ( ), from Latin , meaning “one’s own”, “individual” and perception, is the sense of the relative position of neighbouring parts of the body and strength of effort being employed in movement. It is provided by proprioceptors in skeletal striated muscles and in joints. It is distinguished from exteroception, by which one perceives the outside world, and interoception, by which one perceives pain, hunger, etc., and the movement of internal organs. The brain integrates information from proprioception and from the vestibular system (vestibule of the ear) into its overall sense of body position, movement, and acceleration…