Test · 5
Stance & gait
Standing still and walking are integration tasks — visual, proprioceptive, and vestibular inputs converging. Removing one input at a time reveals which is carrying the patient, and which has failed.
Romberg and sharpened Romberg
Ask the patient to stand with feet together, arms by the sides, eyes open — then closed. If they're steady with eyes open but unsteady with eyes closed, the Romberg is positive: vision was carrying them, and the underlying loss is sensory (vestibular or proprioceptive).
Romberg is non-lateralising — it does not tell you which labyrinth is affected, only that sensory inputs (vestibular and/or dorsal-column proprioceptive) are inadequate without visual fixation. Acute unilateral vestibulopathy tends to fall toward the lesion side; bilateral vestibulopathy produces dramatic eyes-closed instability that may improve with a wider stance or holding on.
The sharpened (tandem) Romberg increases sensitivity by narrowing the base of support — useful for unmasking compensated unilateral vestibular loss after the standard test is negative. A negative cerebellar gait test with a positive Romberg supports a sensory rather than cerebellar cause.
Treat with caution in falls-risk patients and provide standby support. The CTSIB framework (eyes open/closed × firm/foam) probes visual, vestibular, and proprioceptive contributions systematically and guides vestibular rehabilitation strategy.
Stable with eyes open; visual dependence unmasked on closing the eyes. Tandem or foam stance dramatically amplifies the eyes-closed sway, often toward the lesioned side.
Standard (feet together). Classical Romberg. Sensitive for moderate deficits; misses compensated cases.
Fukuda / Unterberger stepping
The patient marches in place with eyes closed and arms outstretched for 50–100 steps. Rotation of more than ~30° from the start line suggests vestibulospinal tone asymmetry — typically toward the side of unilateral vestibular hypofunction.
Fukuda and Unterberger are often used interchangeably (with minor procedural differences). Sensitivity and specificity are modest — the test is best used as an adjunct alongside HIT, nystagmus, and history. Cerebellar lesions produce irregular drift rather than consistent rotation; proprioceptive loss or hip pathology can confound results.
A positive Fukuda with normal HIT and no nystagmus might reflect a compensated old vestibulopathy or a non-vestibular contribution — interpret cautiously and with the full battery.
Right vestibular hypofunction — rotation toward the right. Rotation > 30° after 50–100 steps is the classical Fukuda positive. The test is adjunctive: pair it with HIT, nystagmus, and history before drawing conclusions.
Past pointing and tandem gait
Past pointing: the patient raises an arm overhead and brings it down to touch the examiner's finger with eyes closed. Drift toward one side on repeat is consistent with that side's vestibular hypofunction.
Tandem gait: heel-to-toe walking along a straight line. Stepping off the line, wide base, or freezing each implicates a different system — cerebellar, vestibular, or functional.
Past pointing is lateralising adjunct; asymmetric overshoot/dysmetria with irregular trajectory implicates cerebellar disease instead. Tandem gait is one of the most sensitive bedside tests for cerebellar disease and PSP.2
Pair tandem gait with the Timed Up & Gofor a quick falls-risk read in older adults — >12 s predicts increased fall risk and is a useful pre-discharge benchmark.1
Consistent drift of the pointing arm to the right (side of the lesion) when the eyes are closed. Vision corrects the error.