|Year : 2019 | Volume
| Issue : 2 | Page : 66-70
Usefulness of modified Romberg test in screening persons with vestibular dysfunction
Amit Patil1, Sharda Ajay Sarda2
1 Department of Audiology and Speech Language Pathology, Aditya Birla Memorial Hospital, Pimpari, Pune, Maharashtra, India
2 School of Audiology and Speech Language Pathology, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra, India
|Date of Web Publication||16-Aug-2019|
Dr. Sharda Ajay Sarda
School of Audiology and Speech Language Pathology, Bharati Vidyapeeth (Deemed to be University), BV (Deemed University), Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Development of age-appropriate clinical norms is needed for modified Romberg test (MRT) in the Indian scenario. Hence, the present study was undertaken. Objectives: The specific objectives of the study were to investigate the age and gender effect on MRT, comparison of MRT in normal individuals and individuals with vestibular dysfunctions, and association of MRT with caloric and cervical vestibular evoked myogenic potential (cVEMP) test. Materials and Methods: The study involved two groups of participants: Group I had 90 healthy individuals (45 males and 45 females) and Group II had 30 individuals with vestibular dysfunction. MRT was administered on both the groups. Furthermore, participants of Group II underwent caloric and cVEMP test. Results: It was observed that scores of MRT reduced with increase in age among the participants of Group I. However, gender did not show any significant effect for MRT. On comparison, MRT revealed that healthy participants performed superior to individuals with vestibular dysfunction. Further, correlation analysis between MRT with caloric test and cVEMP showed poor association between them (P > 0.05). Conclusions: MRT is affected by age, and therefore, age-specific norms for MRT are required for each clinic.
Keywords: Caloric test, cervical vestibular evoked myogenic potential test, modified Romberg test, vestibular dysfunctions
|How to cite this article:|
Patil A, Sarda SA. Usefulness of modified Romberg test in screening persons with vestibular dysfunction. Indian J Otol 2019;25:66-70
| Background|| |
Giddiness, a frequently found symptom, is defined as “a sensation of perturbed body equilibrium in relation to the environment.” Body equilibrium depends on the integrity and coordination of the information derived from the vestibular, visual, and proprioceptive systems with the central nervous system. Among all the systems, the vestibular system is integral and cardinal system for balance control. The semicircular canals and otolith organs provide continuous input to the brain about rotational and translational head motion and the head's orientation relative to gravity. This information from the vestibular organs and their central pathways allows for the maintenance of gaze and postural stability by means of vestibulo-ocular reflex (VOR), vestibulo-spinal reflex (VSR), and vestibulocollic reflex. VSR and integration ability of all the three system is assessed using posturography test, Fukuda Stepping test, craniocorpography, Romberg test, and modified Romberg (sharpened Romberg) test (MRT).
The MRT has been proposed as a screening tool for measuring the postural sway among individuals with vestibular dysfunction. It has been recommended to be administered in eye-close versus eye-open condition and on compliant versus noncompliant surface clinically to identify whether individual is at the risk of having vestibular dysfunction.
Aim and objectives of the study
The purpose of the present research was to study the MRT in normal individuals and individual with vestibular dysfunction. The following objectives were studied.
The objectives of the study were to determine the age and gender effect on MRT on compliant versus noncompliant surface and eye-open versus eye-close task in normal individuals and individuals with vestibular dysfunction. The present study also assessed if the scores associated with caloric and or cervical vestibular evoked myogenic potential (cVEMP) test.
| Materials and Methods|| |
It was a prospective, randomized controlled experimental study.
The study was approved by the Ethical Committee of the Bharati Hospital and Research Center. Participant's information sheet and consent form were explained to the all participants and were asked to sign before enrolling them in the study.
For assessing the performance MRT, compliant surface (4.5 inches of thickness), developed at Bharati Vidyappeth deeemed to be University, School of Audiology and Speech Language Pathology and a case history designed for client with giddiness was used.
Digital stopwatch for computing the number of seconds for which participants could stand without losing his/her balance on MRT. SYNAPSYS Digital-Nystagview V3.2 RevL with Ulmer video nystagmoscopy goggle (VNS 3X) developed by for caloric testing was used for performing caloric test. calibrated 2 channel Madsen OB922 diagnostic audiometer was utilized to do pure tone audiometry. Calibrated Amplaid-756 screening immittance meter was used for assessing middle ear status. Nicolet Viking Quest Master software V8.1 was used for performing cVEMP for the participants of Group II
Two groups of participants were included in the study. Group I involved 90 normal individuals (45 males and 45 females). [Table 1] shows the distribution of participants as per the age groups.
Group II consisted of 30 individuals with vestibular dysfunction. Participants with abnormal values on caloric test and/or cVEMP (valued more than the normative value ±2 standard deviation [SD] values of the normative data) were considered for the study. Normative data were already developed at the audiovestibular laboratory of the current research center and have been used as a reference.
Participants of Group I and Group II had performed MRT in following test conditions, that is, eye-open (Eo) compliant surface, eye-close (Ec) compliant surface, Eo noncompliant surface, and Ec noncompliant surface. The MRT was performed in a heel-to-toe standing position as shown in the [Figure 1]. Timing was stopped when participants were moved their feet from the proper position or when they opened their eyes or if they reached their maximum balance times of 60 s. Furthermore, participants of Group II were undergone through caloric test and cVEMP test as well. In caloric test, cold (27°C ± 0.4°C) and warm (44°C ± 0.4°C) air irrigation were delivered for 45 s. Slow-phase velocity and canal paresis was recorded after caloric test using the Jongkees formula (5).
Jongkees formula for canal paresis % (1962) is given below:
where RW-Right ear warm response, RC-Right ear cold response, LW-Left ear warm response, and LC-Left ear cold response.
Patient's alertness was maintained throughout the test by giving suitable mental tasks.
Further cVEMP was recorded using the following stimulus and acquisition parameters [Table 2] and [Table 3].
|Table 2: Stimulus protocol of cervical Vestibular Evoked Myogenic Potential (cVEMP)|
Click here to view
|Table 3: Acquisition parameters of cervical evoked myogenic potential (cVEMP)|
Click here to view
| Results|| |
To study the stated objectives scores of MRT in seconds for the given test conditions i.e., Eo compliant surface, Ec compliant surface, Eo noncompliant surface, Ec noncompliant) surface served as dependent variables, while groups as per age and gender served as independent variable. Test of normality was carried out using Shapiro–Wilks test which revealed nonnormal distribution of data (P < 0.05). As data were not normally distributed, nonparametric test was carried out to study the stated objectives.
To study the age and gender effect on MRT, the first mean and SD values for Eo and Ec conditions were measured in all three age groups. [Graph 1] [Table 4] shows mean and standard deviation for Group I.
|Table 4: Mean and standard deviation values for modified Romberg test among the participants of Group Ia, Group Ib, Group Ic|
Click here to view
[Table 4] shows that mean score for MRT is reducing from Group Ia to Group Ib to Group Ic. This trend is noticed for all the four conditions, i.e., Eo on compliant surface, Ec on compliant surface, Eo on noncompliant surface, and Ec on noncompliant surface. Furthermore, to analyze if there is statically significant difference exits or not on MRT scores across three age group nonparametric test of ANOVA, i.e., Kruskal–Wallis test was used. Pairwise comparison was done subsequently across these three age groups.
A Kruskal–Wallis H-test showed that there was a statistically significant difference in all task of MRT for different age group (P < 0.01) as shown in [Table 5]. Furthermore, to investigate statistical difference within-group pairwise comparison was done by applying, nonparametric Mann–Whitney U-test which showed that there was a significant difference across all the age groups (P < 0.05).
|Table 5: Z, P, and df value of Kruskal-Wallis test among participants of Group Ia, Group Ib, and Group Ic|
Click here to view
To investigate the effect of gender on MRT Mann Whitney U test was used which showed no significant difference found between male and female on MRT for all four test conditions (P > 0.05).
Furthermore, effect of compliant versus noncompliant surface among normal individuals (Group I) and individuals with vestibular dysfunction (Group II) was studied using Wilcoxon signed-rank test. The result of this objective revealed that there was a statistically high significant difference between the scores of MRT for compliant versus noncompliant surface among the participants of Group I (normal individual) and Group II (P < 0.01).
Similarly, statistically significant difference was observed when MRT scores were compared between Eo and Ec conditions in Group I and Group II using Wilcoxon signed-rank test (P < 0.01).
To compare scores of MRT among the participants of Group I and Group II, Mann–Whitney U-test was applied. Score of MRT achieved for the participants of both the groups. However, for comparing the age-matched healthy participants with the clinical group, only the first-age group of normal participants with the age range of 40–50 years were considered. The result revealed statistically significant difference across all the four test conditions of MRT (P < 0.01).
To study the relationship of MRT with caloric test and cVEMP in Group II, Kendall's Tau b test was applied. The result showed that there was no significant relationship of Ec task of compliant surface with canal paresis, p13 latency, n23 latency of cVEMP, and interaural amplitude asymmetry ratio of cVEMP. Statistical values on correlational analysis between MRT on Ec compliant surface and canal paresis was r = 0.16, P > 0.05, Similarly, between Ec complaint surface and amplitude asymmetry ratio was r = 0.66 P > 0.05, Ec complaint surface and p13 latency was r = 2.50, P > 0.05, and Ec complaint and n23 latency was r = 1.98, P > 0.05.
| Discussion|| |
The results of the first objective revealed a significant age effect on MRT among the normal individuals (Group I). Furthermore, agewise significant difference was shown across all the test conditions of MRT, i.e., Eo task on compliant surface, Eo task on noncompliant surface, Ec task on compliant surface, and Ec task on noncompliant surface. The mean values of all the task of MRT had reduced from Group Ia to Group Ib to Group Ic. Similar findings have been reported in the past., Reduced performance on MRT with advancing age has been attributed to the depletion of vestibular hair cells and loss of vestibular ganglion cells associated with the age.,,,, They have reported a decrease in the number of vestibular hair cells after the age of 20-year-old and a decrease in the number of vestibular ganglion neurons after the age of 50 years. It was also reported that imbalance on balance test may be due to deterioration in the sensory, visual, vestibular, neurologic, and muscular system and function of these components with advancing age., However, the mean score of MRT test in the present research has been observed to be higher across all conditions than what is reported in the literature. This discrepancy in the result could be due to the variation in the inclusion criteria of the studied participants. It has been seen that numerous authors have considered age range up to 80 or above for studying age effect on MRT.
On investigating an effect of gender, it was revealed that there was no significant difference on MRT between male and female participants. The present findings support the reports by earlier researchers. No significant difference on MRT between the gender groups indicates that physiological difference between healthy male and female do not affect the balance test such as MRT. However, such gender differences exist or not in the clinical population cannot be commented based on the findings in normal population as inherent vestibular pathology may portrait differently across two genders on balance test.
Furthermore, participants of the present study performed better on noncompliant surface than complaint surface. This can be attributed to the maintenance of body equilibrium by means of three sensory system, i.e., proprioceptive, vestibular, and visual system. Therefore, once the support of prospective sensory system was eliminated by means of testing in compliant surface, it resulted into shorter duration of balance on MRT. The present findings are in accordance with the earlier reports. On comparing Ec task of MRT with Eo task, balance was maintained for longer duration in Eo task than Ec task of MRT. Present findings on this measure are in consensus with earlier studies.,, They have reported that individuals with and without vestibular dysfunction perform superior on Eo task of MRT. Poor score of MRT in Ec task could be due to higher burden on vestibular and proprioceptive senses as visual system is eliminated during Eo task of MRT.
It was further noticed that significant difference was found in both normal individuals as well as individuals with vestibular dysfunction. However, more imbalance was noted on MRT for clinical population as compared to normal population could be due to impaired vestibular reflexes observed in the present clinical population. It is known that abnormal functioning of vestibular reflexes such as vestibular ocular reflex, vestibulocollic reflex (VCR), and/or vestibular spinal reflex results into poor performance on balance test.,, Similar results have been documented by Evans and Krebs in 1991, who had reported that individual with unilateral vestibular dysfunction experiences unsteadiness while performing balance test due there asymmetry in functioning of the vestibular system. The other reason for poor performance on MRT in clinical group could be due to the associated symptoms commonly found among the participants with vestibular dysfunction such as nausea, unsteadiness during standing positions, and motion intolerance.
On correlation analysis, it was observed that MRT was not associated with either caloric test or cVEMP. The present results partially support the findings of earlier studies by Murray et al. in 2007 who have reported that otolith dysfunction does not significantly influence the balance performance of individuals with peripheral vestibular disorder. The present reports show that caloric test affects the balance performance as indicated in previous objective, however; it does not hold linear relationship with balance. This could be due to numerous variations among the participants of Group II such as site of pathology, extent of pathology, prolonged intake of antivertiginous medications, symmetrical versus asymmetrical vestibular pathology, amount of compensation by central vestibular system, and time since the problem is existing. Another possible reason for not showing relationship of MRT with caloric test and cVEMP test could also be due to the different pathways assessed by these three tests. It is known that caloric test assesses vestibuloocular reflex. However, VCR is assessed by cVEMP test and MRT in Ec on compliant surface predominantly assess vestibulospinal reflex.
| Conclusions|| |
The MRT can be a useful screening tool if age-specific norms are available for every clinic. Nevertheless, it cannot replace the objective tests such as caloric test and cVEMP.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Maurer C, Mergner T, Bolha B, Hlavacka F. Vestibular, visual, and somatosensory contributions to human control of upright stance. Neurosci Lett 2000;281:99-102.
Lychakov DV, Rebane YT. Otolith regularities. Hear Res 2000;143:83-102.
Heitmann DK, Gossman MR, Shaddeau SA, Jackson JR. Balance performance and step width in noninstitutionalized, elderly, female fallers and nonfallers. Phys Ther 1989;69:923-31.
Agrawal Y, Carey JP, Hoffman HJ, Sklare DA, Schubert MC. The modified Romberg balance test: Normative data in U.S. Adults. Otol Neurotol 2011;32:1309-11.
Sarda S, Bhat S, Vanaja CS. Variation in the gaze, caloric test and vestibular-evoked myogenic potential with advancing age. Indian J Otol 2014;20:4-9. [Full text]
Thyssen HH, Brynskov J, Jansen EC, Münster-Swendsen J. Normal ranges and reproducibility for the quantitative Romberg's test. Acta Neurol Scand 1982;66:100-4.
Bohannon RW, Larkin PA, Cook AC, Gear J, Singer J. Decrease in timed balance test scores with aging. Phys Ther 1984;64:1067-70.
Johnsson LG, Hawkins JE Jr. Vascular changes in the human inner ear associated with aging. Ann Otol Rhinol Laryngol 1972;81:364-76.
Igarashi M, Saito R, Mizukoshi K, Alford BR. Otoconia in young and elderly persons: A temporal bone study. Acta Otolaryngol Suppl 1993;504:26-9.
Girardi M, Konrad HR, Amin M, Hughes LF. Predicting fall risks in an elderly population: Computer dynamic posturography versus electronystagmography test results. Laryngoscope 2001;111:1528-32.
Agrawal Y, Ward BK, Minor LB. Vestibular dysfunction: Prevalence, impact and need for targeted treatment. J Vestib Res 2013;23:113-7.
Richter E. Quantitative study of human Scarpa's ganglion and vestibular sensory epithelia. Acta Otolaryngol 1980;90:199-208.
Barin K, Dodson EE. Dizziness in the elderly. Otolaryngol Clin North Am 2011;44:437-54, x.
Lord SR, Clark RD, Webster IW. Postural stability and associated physiological factors in a population of aged persons. J Gerontol 1991;46:M69-76.
Vereeck L, Wuyts F, Truijen S, Van de Heyning P. Clinical assessment of balance: Normative data, and gender and age effects. Int J Audiol 2008;47:67-75.
Black FO, Wall C 3rd
, Rockette HE Jr., Kitch R. Normal subject postural sway during the Romberg test. Am J Otolaryngol 1982;3:309-18.
Nandi R, Luxon LM. Development and assessment of the vestibular system. Int J Audiol 2008;47:566-77.
Briggs RC, Gossman MR, Birch R, Drews JE, Shaddeau SA. Balance performance among noninstitutionalized elderly women. Phys Ther 1989;69:748-56.
Franchignoni F, Tesio L, Martino MT, Ricupero C. Reliability of four simple, quantitative tests of balance and mobility in healthy elderly females. Aging (Milano) 1998;10:26-31.
Smith RG, Betancourt L, Sun Y. Molecular endocrinology and physiology of the aging central nervous system. Endocr Rev 2005;26:203-50.
Agrawal Y, Carey JP, Della Santina CC, Schubert MC, Minor LB. Disorders of balance and vestibular function in US adults: Data from the national health and nutrition examination survey, 2001-2004. Arch Intern Med 2009;169:938-44.
Srulijes K, Mack DJ, Klenk J, Schwickert L, Ihlen EA, Schwenk M, et al.
Association between vestibulo-ocular reflex suppression, balance, gait, and fall risk in ageing and neurodegenerative disease: Protocol of a one-year prospective follow-up study. BMC Neurol 2015;15:192.
Bath AP, Harris N, Yardley MP. The vestibulo-collic reflex. Clin Otolaryngol Allied Sci 1998;23:462-6.
Evans MK, Krebs DE. Posturography does not test vestibulospinal function. Otolaryngol Head Neck Surg 1999;120:164-73.
Brandt T, Dieterich M. Vestibular falls. J Vestib Res 1993;3:3-14.
Murray KJ, Hill KD, Phillips B, Waterston J. The influence of otolith dysfunction on the clinical presentation of people with a peripheral vestibular disorder. Phys Ther 2007;87:143-52.
Shepard NT, Jacobson GP. The caloric irrigation test. Handb Clin Neurol 2016;137:119-31.
Clarke AH, Schönfeld U, Helling K. Unilateral examination of utricle and saccule function. J Vestib Res 2003;13:215-25.
Rikli RE, Jones CJ. Assessing physical performance in independent older adults: Issues and guidelines. J Aging Phys Act 1997;5:244-61.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]