Low Back Pain Related to Hyperlordosis

Original Editors - Leen Meylemans

Top Contributors - Lise Buelens, Leen Meylemans, Claudia Karina, Loes Verspecht, Gertjan Peeters, Lucinda hampton, 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):
     o Obesity
     o Poor abdominal muscle strength and imbalance in trunk muscle strength (1: 2B) (3: 2B)
     o Reduced spinal mobility
     o Tight hamstrings
     o Differences in leg length between the right and left leg
     o Decreased back extensor muscle endurance (4: 2B)
     o 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:
     o congenital spine deformities
     o anterior tilt of the hip
     o short back muscles
     o 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:
     o Compression fracture (Link physiopedia: Lumbar compression fracture)
     o Spondylosis and spondylolysthesis (link physiopedia: lumbar spondylosus) + (Link physiopedia:                      spondylolisthesis)
     o Tumor or metastasis
     o Tears in ligaments or muscles
     o Cauda equina syndrome (Link physiopedia: Cauda Equina Syndrome)
     o 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)
     o Weight loss, without an indication.
     o age: < 20 years old and > 55 years old
     o Comorbidities or previous history of cancer, HIV, infections,...
     o Widespread neurological symptoms
     o Night pain
     o Bladder dysfunction
     o Trauma
     o ...

Diagnostic Procedures

• Medical imaging (9)
     o 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:
     o Between the inferior endplate of T12 and the superior endplate of S1: This one had the best intraobserver reproducibility.
     o Between the superior endplate of L1 and the superior endplate of S1
     o Between the superior endplate of L1 and the inferior endplate of L5 (2: 2B): This one had the best overall agreement between several observers
     o 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)

Medical Management ^{[31 LOE= 2A,16 LOE= 2B,21 LOE= 3A ]} 

Since lumbar hyperlordosis is just a contributing factor in producing low back pain we need to look further for other causes. When serious and specific causes of low back pain have been ruled out we can follow the NICE guidelines for early management. [31]

Information, education and patient preferences

Provide people with advice and information to promote self-management of their low back pain.
1. Offer educational advice that:
○ includes information on the nature of non-specific low back pain
○ encourages the person to be physically active and continue with normal activities as far as possible.
2. Include an educational component consistent with this guideline as part of other interventions, but do not offer stand-alone formal education programmes.
3. Take into account the person's expectations and preferences when considering recommended treatments, but do not use their expectations and preferences to predict their response to treatments. [31]

Pharmacology

First medication option should be regular paracetamol. When paracetamol alone provides insufficient pain relief, offer non-steroidal anti-inflammatory drugs (NSAIDs) and/or weak opioids (codeine and dihydrocodeine). Give due consideration to the risk of side effects from NSAIDs, especially in older people and other people at increased risk of experiencing side effects.[31]

Surgery

Surgical intervention can be considered when the lumbar lordosis curve is severe, the conservative treatment alone failed and if there are signs of neurologic involvement. Signs of neurologic involvement are loss of sensory perception of touch, loss of reflexes and loss of muscle fiber recruitment [49]. Surgical correction can be done anteriorly and posteriorly. [16,21]

Physical Therapy Managment ^{[41 LOE= 1A, 43 LOE=1A, ,20 LOE= 1A ,22 LOE = 3A, 42 LOE= 1B, 43 LOE= 1A, 23 LOE= 1B, 24 LOE=2A, 37 LOE=2C, 35 LOE= 1B]}

Physical therapy management should be aimed towards improving the patient’s ADL and reducing low back pain. As discussed before, the factors contributing to the LBP can be very diverse. And it is of course important to know what the causing factors are and to treat these factors. It is important to set therapeutic goals that are realistic for the patient.
Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in health care populations. In subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes, though evidence for other types of exercise is unclear. In acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments. [41]
Above all else, you need to be certain that there are no indications for surgery. It’s beneficial to start with physical therapy in combination of medication.

Exercise therapy, which beholds strengthening exercises, isometric and isotonic exercises, stretching exercises, lifting techniques and endurance training, is proven to be successful against low back pain. [20]
Strengthening of the deep abdominal musculature, also isometric and isotonic exercises may be beneficial for strengthening of the main muscle groups of the trunk, which stabilizes the spine. It can also decrease the pain.
Decreasing the extension forces on the lumbar spine is the purpose of these exercises. This can result in a decreased lumbar lordosis. [20]

For improving the mobility of the patient, you can perform stretching of the hamstrings, hip flexors and lumbar paraspinal muscles.

For variation you can perform other sports, the recommended sports are walking swimming and cross-training.
You can best avoid contact sports like basketball. [22]

Exercises should be done on a regular basis to reach maximum effect.

Sling exercise training seems to be effective at reducing the pain intensity and disability levels of LBP patients. [42]

Through core strength training, patients with chronic low back pain can strengthen their deep trunk muscles. [43] For enhanced exercises that maintain this aspect of training we refer to the core stability page on physiopedia.

Exercise for strengthening the deep abdominal muscles.
The patient must alternate the legs, with leg extension while exhaling, maintaining contraction of transversus abdominis, paravertebral and pelvic floor muscles. [23]

A recent study proves that stretching of M. Iliopsoas is beneficial. It reduces pain intensity, lumbar lordosis and increased the iliopsoas muscle.
The patient must perform a submaximal voluntary isometric contraction of the M. Iliopsoas for 10 seconds. Afterwards the muscle contraction is stopped for 10 seconds. The participant’s leg is slowly moved to a new range until a mild stretching sensation is felt and described by the patient. Afterwards this position is held for 20 seconds. This was repeated 5 times and was followed by a 1 min rest. [24]

Another stretching technique for improving the ROM of the M.Iliopsoas and the M. Rectus femoris: the patient lies in thomas position, the not stretched leg is maximally flexed to stabilize the pelvis and flatten the lumbar spine. The other leg is in a normal flexed position because of the tightness of the M. Iliopsoas. It’s this leg that needs to be pushed against the table.
If you want to stretch the M. rectus femoris, bend the knee more than 90°, while performing the same stretch. [37]

Lower crossed syndrome
With a crossed leg syndrome type a problem it’s beneficial to stretch the tightened muscles. If you would train on strength it would worsen the condition of the patient.
Another study shows that it’s beneficial to stretch over 15 seconds. This will improve the active and the passive ROM in the lower extremity. [35]

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)

Failed to load RSS feed from http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1vic32dnWqLVVL07dQ4R5YLt038VaZ4N-OU6alcKTXhyihes5I|charset=UTF-8|short|max=10: Error parsing XML for RSS