Low Back Pain Related to Hyperlordosis

Is there a relationship between low back pain (LBP) and hyperlordosis?[edit | edit source]

Is there a relationship between low back pain (LBP) and hyperlordosis?

A 2004 studyCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title and a 2003 studyCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title found that there is no significant difference in lumbar lordosis between people with LBP and people without LBP. A 1999 studyCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title concluded that there were no statistically significant differences in thoracic kyphosis, lumbar lordosis and sacral inclination between people with acute LBP, people with chronic LBP and a control group. Also a 2 other studiesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title found no statistical difference in sacral inclination angle, lumbosacral angle, sacral horizontal angle and total and segmental lordosis angles between acute LBP patients and chronic LBP patients. Another studyCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title concluded that there is a relationship between LBP en muscle weakness, but they also concluded that structural factors – such as the size of the lumbar lordosis and the pelvic tilt – are not associated with LBP. Also Kim HJ et al.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title concluded that an imbalance in trunk muscle strength can influence the lumbar lordosis. Furthermore this study also found that it is generally assumed that these muscles affect the shape of the lumbar spine and might be one risk factor for potential low back pain. But we also found a studyCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title that concluded that the lumbar lordosis was significantly less in the LBP group compared with the group without LBP.

Despite the conclusion of this last study, it is – based on all the above studies – not reasonable to conclude that there is a relationship between LBP and the size of the lumbar lordosis. On the other hand it is likely that trunk muscles weakness can influence the shape of the lumbar lordosis and might be a cause of LBP.

Clinically Relevant Anatomy[edit | edit source]

The lumbar spine has an inward curvature or lordosis. A normal lumbar lordosis is characterized by a lumbosacral angle of 140°[9]. However, when the curvature of the lumbar spine is very pronounced, we talk about hyperlordosis or swayback. In case of hyperlordosis the lumbosacral angle increases and the lumbar index (the chord of the lumbar lordosis) also increases[9]. The causes of a hyperlordosis vary: congenital spine deformities, an anterior tilt of the hip, short back muscles and thigh and hamstrings that are too weak. The last mentioned is due to a muscular imbalance, also known as lower crossed syndrome. the postural muscles shorten in response to stress and they in turn inhibit their antagonists.(see figure 2). A 2011 study found that the use of high-heeled shoes is correlated with increased lumbar lordosis and pelvic anteversion while standing.[33]

Increased lordosis.png

Women have less vertebral wedging in the lower thoracic and upper lumbar vertebrae, they have relatively greater interspinous space and larger inter facet with in lumbar hyperlordosis in females. These anatomical features could explain the altered vertebral morphology predisposing to pregnancy.
Women also have a less kyphotic posture of the upper and the lower thoracic area than males. Furthermore the trunk’s center of mass is maintained in an approximate sagittal alignment with the hip thus reducing biomechanical load and facilitating spinal extension.
There is an advantage of this deeper lordosis- less kyphotic female spine, the advantage is that, there is a larger superior-inferior space for the human fetus.
The downside of this morphological feature is the resultant size reduction of the intervertebral foramen which in turn may contribute to low back pain commonly experienced in pregnancy. [17]

Epidemiology /Etiology [36 LOE=2B, 26 LOE = 1B, 25 LOE= 1B, 27 LOE= 2B, 28 LOE= 1B,, 29 LOE= 2A, 30 LOE= 2B ,32 LOE = 2B, 33 LOE= 2B, 38 LOE= 3A, 39 LOE= 2B, 40LOE = 2B][edit | edit source]


Several studies have concluded that low back pain is not directly related to lumbar hyperlordosis. There are factors that contribute to a higher amount of lumbar lordosis. These etiological factors in turn can cause low back pain. But it is important to mention that not solely the lumbar hyperlordosis is the causing factor for low back pain.
A 2004 study[1] and a 2003 study[2] found that there is no significant difference in lumbar lordosis between people with LBP and people without LBP. A 1999 study[3] concluded that there were no statistically significant differences in thoracic kyphosis, lumbar lordosis and sacral inclination between people with acute LBP, people with chronic LBP and a control group. Also 2 other studies[4][5] found no statistical difference in sacral inclination angle, lumbosacral angle, sacral horizontal angle and total and segmental lordosis angles between acute LBP patients and chronic LBP patients. Alireza et al, found no significant correlation between the degree of lumbar lordosis and the score of functional disability with regards to different age groups and gender.[36] Another study[6] concluded that there is a relationship between LBP and muscle weakness, but they also concluded that structural factors – such as the size of the lumbar lordosis and the pelvic tilt– are not associated with LBP. Williams et al said that the tightness of back extensor muscles as well as the weakness of abdominal muscles due to prolonged sitting are an important factor in increasing the lordosis angle.[26]Also Kim HJ et al.[7]concluded that an imbalance in trunk muscle strength can influence the lumbar lordosis. Furthermore this study also found that it is generally assumed that these muscles affect the shape of the lumbar spine and might be one risk factor for potential low back pain. But we also found a study[8] that concluded that the lumbar lordosis was significantly less in the LBP group compared with the group without LBP.
Another recent study concluded that an improvement in lumbar lordosis, thoracic kyphosis, sacral slope and positioning of c7 plumb line decreases the pain and disability in patients with chronic mechanical low back pain. Therefore, changes in lordosis angle may be one of the contributing factors in producing low back pain.[25] Despite the conclusion of these two last studies, it is – based on all the above studies – not reasonable to conclude that there is a relationship between LBP and the size of the lumbar lordosis. On the other hand it is likely that trunk muscles weakness can influence the shape of the lumbar lordosis and might be a cause of LBP.
A study from Lee et al investigated trunk muscle weakness in asymptomatic volunteers and saw that an imbalance in trunk muscle strength ( a lower extensor strength than flexor muscle strength) might be a risk factor for low back pain.[27] Other studies also concluded that weakness of superficial trunk and abdominal muscles are an important risk factor for low back pain. [28,29] A study of Ferreir et al. demonstrated that the musculus transversus abdominus had insufficient control and speed of muscle contraction delayed in individuals with chronic low back pain. [30] Beside the muscle weakness Nourbakhsh et al. found no indication that the length of abdominal, hamstring and iliopsoas are associated with the occurrence of low back pain. [6] However a more recent study of 2015 showed that stretching of the iliopsoas ,using the hold-relax technique, reduces pain and lumbar lordosis angle.[32]

Beside the congenital diseases and the identified relationship between an imbalance in trunk muscle strength and the lumbar lordosis there is also a common external factor that could increase the lumbar lordosis. A 2011 study found that the use of high-heeled shoes is correlated with increased lumbar lordosis and pelvic anteversion while standing.[33] Another study concluded that high-heeled shoes can lead to the development of postural disorders such as a forward head posture, lumbar hyperlordosis and a pelvic anteversion.[38] A 2013 study compared the effects of different heel inclinations on the changes of lumbosacral biomechanical angles in students with lumbar hyperlordosis and found no significant difference. However there was a little more change in the group standing on negative inclination.[39] In contrast to these studies, another study concluded that high heeled shoes did not affect lumbar lordosis in most people while standing.[40]

Characteristics/Clinical Presentation [46 LOE= 3A, 48 LOE= 5]
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Lumbar hyperlordosis is known as ‘swayback’ or ‘hollow back’. The buttocks are much more prominent [46].
Gender differences as discussed above. There is an increasing recognition of the importance (functional & clinical) of lumbar lordosis. It is a key feature in maintaining sagittal balance. It has been claimed that flattening or loss of normal lumbar lordosis is an important clinical sign of back problems [48].


Differential Diagnosis[edit | edit source]

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Diagnostic Procedures[edit | edit source]

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Outcome Measures[edit | edit source]

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Examination[edit | edit source]

As we assume that the muscles around the lumbar spine (abdominal, extensors of the spine, hip flexors, hamstrings and quadriceps) have an influence on the lumbar spine, it may be useful to measure and/or inspect the lumbar lordosis. An inspection can provide valuable information on muscle weakness. Therefore, it is recommended not to skip the inspection. We look at the depth of lumbar lordosis and any sagittal deviations. But an inspection remains subjective, therefore we also can use a number of instruments to measure the lumbar lordosis, such as the flexible ruler. However, several studies indicate that the reliability of this instrument remains a matter of debate. Bryan JM et al.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title concluded that the flexible ruler a poor validity has in the assessment of actual lumbar lordosis. And Franklin W Lovell et al.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title concluded that the flexible ruler might be reliable as clinical measurement of lumbar lordosis, but only if it is taken by the same therapist over a short period of time.

Medical Management
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Key Research[edit | edit source]

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Resources
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http://www.nlm.nih.gov/medlineplus/ency/article/003278.htm
http://bigbackpain.com/posture.html#swayback

Clinical Bottom Line[edit | edit source]

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Recent Related Research (from Pubmed)
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References[edit | edit source]