Low Back Pain Related to Hyperlordosis

Original Editors - Leen Meylemans

Top Contributors - Lise Buelens, Leen Meylemans, Claudia Karina, Loes Verspecht, Lucinda hampton, Gertjan Peeters, Cameron Mostinckx, Rishika Babburu, Admin, Kim Jackson, Geubels Kaat, Evan Thomas and Oyemi Sillo  

Search Strategy

We searched for information in different scientific databases like pubmed and web of science.
To obtain the best possible results, we have made following combinations of terms:

Low back pain	Hyperlordosis
Low back pain	Medical management
Hyperlordosis	Medical management
Lordosis	Lordosis/etiology	Lordosis/epidemiology
Lordosis	Lordosis/physiology	Lordosis/physiopathology	lordosis/pathology
Low back pain	Stabilization training
Lordosis	Lordosis/therapy	Lordosis/rehabilitation

   Tabel 1: The terms we used to find information for this page

Definition

“Low back pain (LBP) has been related with anthropometric, postural, muscular, and mobility characteristics” (2: 2B)
Lumbar lordosis is a key feature in maintaining sagittal balance. (7:2A) It is one of the most important parts of the spinal pillar that has a special importance due to the unique position and having a direct contact the pelvis. (6:2B) Sagittal balance or “neutral upright sagittal spinal alignment” is a postural goal of surgical, ergonomic and physiotherapeutic intervention. (7: 2A)
In this page we will discuss the relation between low back pain and hyperlordosis.

Clinically Relevant Anatomy

If a straight lumbar spine articulated with the sacrum, it would consequently be inclined forwards. To restore an upward orientation and to compensate for the inclination of the sacrum, the intact lumbar spine must assume a curve. This curve is known as the lumbar lordosis.(13)

A normal lumbar lordosis is characterized by an average lumbosacral angle of 39° - 53°(9). The results depend on how you measure the lumbosacral angle. When you use radiographs to measure the lumbosacral angle, the angle will be smaller as when you use a flexible ruler. We should note that there is an enormous difference in lumbosacral angle over patients. 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).

In addition to the bones, ligaments, muscles and disci vertebrae have also a key role in lordose formation. Without muscle action, pelvic girdle performance hasn’t sufficient stability. Central stabilize of the vertebral column is supported by special muscles such as multifidus, transversus abdominis and internal muscles in trunk. They provide stability of vertebrae in a focal form and provide also segmental stabilization by controlling motion in the neutral zone. The neutral zone can be regained to within physiological limits by effective muscle control.
The lower crossed syndrome is another example which can cause increased lordosis. (Link physiopedia: Lower crossed syndrome). This syndrome is characterised by tightness of the hip flexors and the erector spinae and an increase in length or weakness of the gluteal and abdominal muscles. (23)

File:Fig a -lower crossed syndrome (24).png                    File:Posture in lower crossed syndrome.png

Fig a: Lower crossed syndrome (24)                                    Fig b: Posture in lower crossed syndrome (24)

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. (15: 1A)

Epidemiology /Etiology

• Is there a relationship between low back pain (LBP) and hyperlordosis?
An increase in lordotic angle proportionally increases the shearing strain or stress in the anterior direction and shifts the center of gravity anteriorly. This increased angle and stress is thought by some to be associated with poor posture and back pain. From a biomechanical point of view, the accentuated lumbar lordosis is associated with an increased prevalence of low back pain. (6: 1B)
However 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, like weakness of the trunk, short back muscles, weak thigh and hamstrings,... in turn can cause low back pain. These etiological factors are described below in item "low back pain related to hyperlordosis". But it is important to mention that not solely the lumbar hyperlordosis is the causing factor for low back pain.
It is thus not reasonable to conclude that there is a relationship between LBP and the size of the lumbar lordosis.(4: 2B) On the other hand it is likely that trunk muscle weakness can influence the shape of the lumbar lordosis and might be a cause of LBP. (6: 1B)

• Epidemiology:
Low back pain is a common health problem in our society. Most people will experience low back pain at some point in their life. The lifetime prevalence of low back pain is reported to be as high as 84% and best estimates suggest that the prevalence of chronic low back pain is about 23%, with 11-12% of the population being disabled by it. All age groups are affected by low back pain. (19)

• Etiology:
There are a lot of etiological factors that can be linked to low back pain (2: 2B):

• Obesity
• Poor abdominal muscle strength and imbalance in trunk muscle strength (1: 2B) (3: 2B)
• Reduced spinal mobility
• Tight hamstrings
• Differences in leg length between the right and left leg
• Decreased back extensor muscle endurance (4: 2B)
• Increased lumbar lordosis

• Low back pain related to hyperlordosis:
The multifidus, transversus abdominis and internal muscles in trunk act late in patients suffered from hyperlordosis. (6: 1B) There is a correlation between weakness of the trunk muscles and an increased lordotic angle, which can be a cause of low back pain (2: 2B). Weakness in any of the muscles of the lumbar-pelvic belt can follow pelvic rotations and diversions of back-arc by impairing muscular balance in this area and thus person can be prone to musculoskeletal disorders. (6: 1B)

There are various factors affecting lumbar lordosis. Some studies show that the range of lumbar lordosis is affected by age, sex, movement in the center of mass such as pregnancy and obesity. (6: 1B) Possible causes of hyperlordosis:

• congenital spine deformities
• anterior tilt of the hip
• short back muscles
• too weak thigh and hamstrings due to a muscular imbalance (lower crossed syndrome): the postural muscles shorten in response to stress and they in turn inhibit their antagonists (see figure 2)
  

Characteristics/Clinical Presentation

Lumbar hyperlordosis is known as ‘swayback’ or ‘hollow back’. The buttocks are much more prominent.
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.
People with low back pain have reduced lumbar ROM and proprioception. They move more slowly compared to people without LBP. (17: 1A)

Differential Diagnosis

It’s essential to make the difference between specific and non-specific low back pain.

• Specific low back pain (11: 1A)
This group of patients had a clear underlying pathology, which causes the low back pain:

• Compression fracture (Link physiopedia: Lumbar compression fracture)
• Spondylosis and spondylolysthesis (link physiopedia: lumbar spondylosus) + (Link physiopedia: spondylolisthesis)
• Tumor or metastasis
• Tears in ligaments or muscles
• Cauda equina syndrome (Link physiopedia: Cauda Equina Syndrome)
• Radiculopathy (Link physiopedia: Lumbar radiculopathy)
  

→ some characteristics (11: 1A)

• Pain in the leg, in the path of the n.ischiadicus
• Paresthesia
• Straight leg raise test is positive
• Loss of power

It is essential to identify these pathologies, because they need a specific treatment.

• Non-specific low back pain (11: 1A)
When there are no red flags and no clear underlying pathophysiology, we talk about non-specific low back pain.

• Red flags (11: 1A; 12)
It’s important to recognize red flags during the anamnesis and during the further examination and treatment, because they can indicate an underlying pathology.
Examples of red flags: (Link physiopedia: Red flags in spinal conditions)

• Weight loss, without an indication.
• age: < 20 years old and > 55 years old
• Comorbidities or previous history of cancer, HIV, infections,...
• Widespread neurological symptoms
• Night pain
• Bladder dysfunction
• Trauma
• ...
  

Diagnostic Procedures

• Medical imaging (9)
Radiographs can be used to measure the lumbar angle. They are the gold standard to evaluate spine curves, but ionising radiations limit routine use. (21) (komt uit het stukje bij examination)

There are several methods to measure the lumbar angle:

• Between the inferior endplate of T12 and the superior endplate of S1: This one had the best intraobserver reproducibility.
• Between the superior endplate of L1 and the superior endplate of S1
• Between the superior endplate of L1 and the inferior endplate of L5 (2: 2B): This one had the best overall agreement between several observers
• Between the inferior endplate of T12 and the inferior endplate of L5

There are several kinds of medical images, which can each be used to diagnose different things. For example: X-rays to measure the lumbar curvature, MRI-scans to investigate soft tissue abnormalities, CT-scans to visualize the discus intervertebralis…

File:The different ways to .png
fig: the different ways to calculate the lumbar angle for an radiography (9).

Outcome Measures

There are identified six main domains relevant to the assessment of patients with low back pain: pain symptoms, function, well being, work disability, social disability and satisfaction with care. These suggestions were made by a group of low back pain experts and were accepted by the spine-research community. Several instruments have been developed and validated for the evaluation of these dimensions. These techniques are especially useful for routine clinical practice or in large-scale quality assessment. (19)
pain symptoms:
function:
     • Oswestry Disability Index is the most effective for persistent severe disability. (Link physiopedia: Oswestry Disability Index)  (31) 
     • Roland-Morris Disability Questionnaire is better for mild to moderate disability. (Link physiopedia: Roland-Morris Disability Questionnaire) (31)

Prevention

Ascertaining the normal values of lordosis in children is essential for early detection and treatment of postural abnormalities. (7: 2B)
The strongest risk factor for future low back pain is previous low back pain. So primary intervention does not seem to be a realistic aim. There are not many strong and alterable factors found, which can cause low back pain for the first time.
Only exercise intervention seems to be effective. (19)
When you combine exercise with education, it also appears to have a positive effect. Other interventions, including education alone, back belts, and shoe insoles, do not appear to prevent LBP. (20: 1A)

Examination

The evaluation depends on age and presence of red flags (→6.differential diagnosis). The examination techniques used to evaluate LBP depend on the population. The activity that reproduces the pain should be evaluated. (14: 2A)

• Inspection
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.

• Evaluation of spine curves 

• Radiographic examination is the gold standard to evaluate spine curves, but ionising radiations limit routine use. (21)
• Non-invasive methods, such as skin-surface goniometer (IncliMed) should be used instead. It is a pocket compass needle goniometer. (21)
• The lumbar angle and sacral angle can be measured with a goniometer. The sacral angle is the angle between the horizontal line parallel to the bottom end and the superior endplate of the sacrum. The lumbar angle can be measured between the Inferior endplate of L5 and the superior endplate of L1: this is called the method of Cobb. (2: 2B) However the reliability of the goniometer is still questioned. (10) (dit is verplaatst van bij diagnostic procedures)
• The flexible ruler may be of clinical value in the assessment of exercise or postural adjustments attempting to increase or decrease a patient's lumbar lordosis. In such an assessment, the flexible ruler would only have to indicate an increased or decreased angle. (10)
• The patient remained in the normal standing posture while lordotic angle was measured.

1. The flexible curve was pressed against the spinous processes of the lumbosacral spine and the points that intersected the adhesive markers were recorded.
2. The points that intersected L1 and S2 were marked and a line was drawn between them.

These two measurements were used to calculate an index of lordosis (Θ), using the following formula: Θ = 4[Arctan2H/L]
(Θ=The index of lordosis, L = the length of the curve and H=the height of the curve.) (6)

• Manual muscle testing
It is commonly accepted that trunk musculature and intra-abdominal pressure produced by muscular activity stabilize spinal structures. Chiropractors and physicians also accepted that abdominal and back musculatures affect pelvic inclination and lumbar lordosis.
There is a relation between the lordotic angle and the flexor-extensor muscle strength. (2: 2B)
We can do manual muscle testing to see if there are muscle weaknesses. By doing the tests we give a score from 0 (no muscle activity) to 5 (normal muscle activity). We will evaluate the muscles during the following  movements:
• Trunk extension (figure 1: score 5)
• Trunk flexion (figure 2: score 5)
• Elevation of the pelvis (figure 3: score 5) (22)
File:Manual1.pngFile:Manual2.pngFile:Manual3.png
figure 1                                                                            figure 2                                                                    figure 3           

Resources

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

Clinical Bottom Line

As far as lumbar hyperlordosis is concerned, we can conclude based on all studies we discussed that it is not reasonable that there is a relationship between low back pain and the size of the lumbar lordosis. however further research in this area is necessary because lumbar lordosis curve evaluation still belongs to one of the routine physical examinations.

Recent Related Research (from Pubmed)

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