Bragard’s Test

What is the Bragard Test?

The Bragard Test (also known as Bragard's Test, Bragards Test, or Bragard's sign) is a clinical provocative test used to assess lower back pain and determine whether it stems from nerve root compression, such as lumbar radiculopathy. This test helps differentiate a genuine Lasegue sign from a false positive, providing clarity in evaluating sciatic nerve irritation.

It is closely related to the Straight Leg Raise Test, as both involve lifting the patient’s leg to provoke symptoms. However, the Bragard Test adds ankle dorsiflexion, a step designed to assess nerve irritation further. This additional maneuver makes it particularly useful for patients presenting with radicular symptoms. The Bragard Test is an essential part of clinical examination and aids in narrowing down the cause of lower back pain before considering more advanced diagnostic options.

The Modified Bragard Test, compared to the original, has slightly different steps: the leg is raised to 70 degrees, and dorsiflexion is performed only after confirming a negative Straight Leg Raise Test result. The modified version has acceptable test performance and diagnostic accuracy with a sensitivity of 69.3% and a specificity of 67.42%, making it better than other clinical provocative tests. The positive predictive value is 73.15%, and the negative predictive value is 63.16%, with a diagnostic odds ratio of 4.63 (Homayouni et al., 2018). Both the original and modified versions are valuable in identifying positive clinical findings and guiding further investigation.

How to perform the Bragard's Test

The Bragard's Test is a straightforward physical examination. It is closely related to the straight leg raising test but incorporates an additional step of ankle dorsiflexion to elicit symptoms more specifically. Here's how to conduct it in clinical practice:

1. Ask the patient to lie down in a supine position on a comfortable examination table, ensuring their legs are straightened.
2. Position yourself by the side of the patient's legs. Gently lift one leg while keeping it straight, slowly moving it into hip flexion. Instruct the patient to notify you if they feel pain or discomfort at any point during the movement.
3. When the patient indicates pain or discomfort, stop lifting the leg but maintain the current position.
4. Lower the leg by about five degrees, then dorsiflex (bend) the ankle firmly backward. Observe for the reproduction of symptoms.

Modified Bragard test

The Modified Bragard Test differs slightly in its procedure. Instead of stopping at the point of pain, raise the leg until 70 degrees and confirm a negative SLR test result. Then, dorsiflex the ankle without lowering the leg. This version is particularly useful for further validating findings in clinical practice.

How to interpret the results of the Bragard's Test

The Bragard's Test interpretation hinges on whether dorsiflexion reproduces the pain or symptoms experienced during leg lifting.

• A positive test result occurs when dorsiflexion elicits pain, particularly if the pain radiates from the lower back to the leg. This outcome suggests potential nerve root compression or sciatic nerve irritation, often linked to lumbar radiculopathy. If the pain is centered around the hip, it indicates lumbar area compression.
• A negative test result means dorsiflexion does not reproduce symptoms, indicating the absence of nerve root irritation or compression.

While Bragard's Test provides valuable insights, it is not definitive. For patients with positive findings, you may need to resort to advanced diagnostic testing and further assessments, such as magnetic resonance imaging (MRI) or complementary clinical tests, may be necessary to confirm a diagnosis and guide treatment.

What are the benefits of the Bragard's Test?

The Bragard's Test offers several advantages in clinical practice, making it a valuable tool for assessing patients with suspected lumbar radiculopathy:

• Efficient and cost-effective: The test is quick to perform, takes only a few minutes, and requires minimal equipment—a comfortable examination table and the examiner’s expertise. This makes it a practical and cost-effective option in busy clinical settings.
• Non-invasive assessment: The Bragard's Test is a non-invasive method that helps identify nerve root irritation or compression without exposing patients to potentially harmful procedures. It provides immediate insights without resorting to advanced diagnostic testing.
• Early detection of nerve involvement: By reproducing pain through dorsiflexion, the test can highlight the presence of lumbar nerve root compression, helping guide early clinical decision-making and ensuring timely referrals for further diagnostic evaluation if needed.
• Monitoring recovery progress: The test can be repeated over time to evaluate the effectiveness of treatments. A reduction or absence of symptoms during subsequent tests may indicate positive treatment outcomes and recovery.
• Differentiation from other causes of pain: When used alongside other clinical provocative tests, the Bragard's Test helps differentiate lumbar radiculopathy from other conditions causing lower back and leg pain, aiding in a more accurate diagnosis.

References

Homayouni, K., Jafari, S. H., & Yari, H. (2018). Sensitivity and specificity of modified Bragard test in patients with lumbosacral radiculopathy using electrodiagnosis as a reference standard. Journal of Chiropractic Medicine, 17(1), 36–43. https://doi.org/10.1016/j.jcm.2017.10.004