Back in 2013, my chiropractor took an X-ray of my neck because I had chronic neck pain. The X-ray not only showed a slight “degeneration” in the anterior part of my C4-C5, it also showed that I have a less than “normal” curvature of my neck. I looked like I had a military neck.

While I did continue a few more treatments in the hopes of either improving the curvature of the cervical spine or reduce the rate at which it is degenerating, eventually, I did not see the point of regularly getting my neck and back cracked. By early 2014, I discontinued treatment when I started to understand that pain is much more complex than just posture and muscles. Maybe there was something else that was contributing to my neck pain other than my lack of cervical lordosis.

What is cervical lordosis?

Lordosis often refers to the concave curvature of the lumbar spine. However, it can also refer to the neck curvature—known as cervical lordosis—which is sometimes related to forward head posture and rounded shoulders.

Lumbar lordosis is often blamed for back pain and neck pain, causing many people to likely seek treatment to reduce the lordotic curve which they believe to be the primary cause of pain. Cervical lordosis—or the lack of it—also tends to get blamed for neck pain and treatment usually tries to increase the curvature of the cervical spine. However, current scientific evidence indicates that straightening of the neck may not be necessary, and chronic neck pain is more complex than just posture alone.

Cervical lordosis vs kyphosis: do they cause neck pain?

The majority of the scientific literature finds a weak association between the degree of cervical lordosis and neck pain.

Early studies of the movement and anatomy of the cervical spine found that there is variability among individuals. One study in 1960 found the movement pattern of the cervical spine is a reflection of the “characteristic of that person.” Therefore, there is no “one average motion that can be ascribed to the cervical spine but rather a range of normal motions,” the author Dr. Malcolm D. Jones wrote.

Later in the 1970s, another study by Dr. Donald C. Weir found that about 20% of 360 patients with no neck pain or other symptoms had a straight or kyphotic curve in their neck when they were examined in a side-lying position. He mentioned that the loss of the cervical lordosis is not “indirect evidence of cervical spine injury” and neck alignment is “highly variable.”

“Straightening or reversal of the cervical lordotic curve may be normal for the individual,” Weir concluded.

A more recent study of 160 X-rays of patients with trauma to the cervical spine also found that the straightening of the cervical spine alone is not a “definitive sign of injury,” but rather it is likely the result of how the patients were positioned when they were in a neck brace and examined in a scan.

While more studies from the 1980s to the 2000s found a poor relationship between the lack of a neck curvature and neck pain, a few studies found more the opposite results and argued the contrary.

In the late 1990s, Deed Harrison, who is a chiropractor from Elko, Nevada, questioned how these studies were performed, such as the way the neck vertebrae were measured. In a paper that was published in 2000, Harrison and his colleagues found that different methods of measurement could give different results.

The Cobb Method is the standard in measuring vertebrae angles, particularly in scoliosis. However, Harrison et al. said in a 2004 paper that it is insufficient because the Cobb Method is unable to find out anything other than the angle between the endpoints of two or more vertebrae. It also has a “high standard error of measurement.”

They said that studies that found no clinically significant relationship between the angle of the cervical lordosis and neck pain measured differently than studies that found some relationship.

They gave one example where one study by Guigui et al. “reported no clinical significance of cervical lordosis” when they measured the posterior parts of the cervical spine at C2 and C7. But another study by Kawakami et al. used “segmental tangents” to measure the neck vertebrae angles, and the degree of cervical lordosis is “correlated to clinical outcomes in cervical spine surgeries.”

In another paper they published in 2004, Harrison et al. compared different measurement methods by using X-rays of 72 people with no neck pain with 52 acute neck pain patients and 70 chronic neck pain patients. They used an ellipses model rather than a circular model that most other studies used to measure the neck angles from the C2 to C7.

Basically, they found that those with acute neck pain had a six degree reduction of the “normal” cervical lordosis, while those with chronic neck pain had a 13 degree reduction. Thus, they concluded that a straighter neck is correlated with the severity of neck pain.

In 2005, McAviney et al. examined 277 neck X-rays of those with or without neck pain. They found a “statistically significant association” between a cervical lordosis angle of less than 20 degrees and neck pain and  a “clinically normal” range of 31 to 40 degrees. Thus, they suggested that getting patients to this range may be a “clinical goal for chiropractic treatment.”

However, a chiropractic study in 2015 found that four weeks of neck adjustments yielded no change of the cervical lordosis when compared to matching health subjects. They also mentioned that their study design did not allow them “to establish a causal relationship between cervical lordosis and pain, nor did it address other clinical outcomes.”

Researchers from the Università degli Studi di Siena in Siena, Italy, reviewed the evidence in 2017–including the evidence by Harrison, McAviney, et al.–and found that neck posture is generally poorly associated with various cervical spine disorders and diseases, such as disk protrusions, stenosis, and spondylosis. They questioned the reliability of imaging and whether surgery is necessary for the lack of a cervical lordosis.

“It is surely difficult to find definite answers considering that pain as a biopsychosocial phenomenon is probably too vast a problem to be simply reduced to any kind of measures, no matter how sophisticated and appealing such a computation may be,” they wrote.

While there is a lack of studies that examines the relationship between cervical kyphosis and neck pain, perhaps the existing body of evidence on cervical lordosis and other types of posture may yield clues to that relationship. However, consider that most of the literature focuses on surgical outcomes and risk assessments on cervical kyphosis due to trauma to the neck, such as a car accident, and other spine pathologies. Such relationship between pain (acute or chronic) and the kyphotic curve of the neck is uncertain.

 Cervical lordosis and the biopsychosocial model of pain

Although there are disagreements about the cause-and-effect relationship between cervical lordosis and neck pain and how neck angles should be measured, the weight of the evidence in the bigger picture still leans on a weak relationship. This can be seen when research examines other factors outside of bones, muscles, and posture.

A cross-sectional study from Curtin University in Western Australia found no relationship among neck posture, headaches, and neck pain among more than 1,100 teens. They found that teens with a forward head posture or slumped posture were more likely to have depression. Those who have a straighter neck posture are more physically active. So, it is likely that neck posture may reflect more on the individual’s lifestyle and behavior rather than pain.

A 2019 systematic review from the University of Cairo examined 13 qualified studies and found that there is a “significant difference” of forward head posture between adults with neck pain than those without neck pain. However, the data does not find such association among teenagers except for those with a “lifetime prevalence and number of doctor visits.”

There were also problems with establishing a specific definition of neck pain across these studies. According to the researchers, the differences among the subjects, experimental setup, and measurement methods made their evaluations difficult to establish any causality.

Because these studies included were cross-sectional, the relationship between neck pain and neck posture “is not possible to establish.” However, it is possible that forward head posture may be an adaptation to pain for some people.

No one knows for sure what exactly causes the straightening of cervical lordosis. Given the existence evidence, it is likely a contribution of many factors, such as genetics, habits, lifestyle, and disease.

Research in lumbar lordosis also found similar results as cervical lordosis. For example, a 2013 review of 120 studies found that such as age, gender, height, weight, ethnicity, and the type of sports participation, “may affect the lordosis angle, making it difficult to determine uniform normal values.” They added that normal lordosis “should be determined based on the specific characteristics of each individual.”

They found a positive relationship between spondylolysis and spondylolisthesis with the degree of the lordotic angle but not spinal degeneration. “Inconclusive evidence exists for association between lordosis and low back pain,” they added. This may be extrapolated to cervical lordosis given the biopsychosocial nature of pain.

Further reading: Pain Is Weird.

Cervical lordosis exercises

Whether someone has a loss of cervical lordosis or not, they can still have chronic neck pain. Therefore, exercise could be one effective method in treating the symptoms of neck pain, according to the current body of research.

One 2017 systematic review from Stellenbosch University in South Africa examined a more specific population: office workers. Pooling data from eight randomized controlled trials, six of these studies found that strengthening the neck and shoulders at least one hour a week could alleviate the symptoms of neck pain when compared to those subjects who did not exercise. Stretching and endurance training on the neck and shoulder provide almost no additional benefit to pain relief or improve the quality of life.

An Australian systematic review also found that strengthening exercises for the neck is effective for pain management, but the effect is “moderate” and small. The researchers also found that psychological treatments or other psychosocial factors (e.g. reassurance, education) alone also have small effects. Thus, they suggest that perhaps a combination of different treatments would be more effective than stand-alones.

They researchers also mentioned that clinicians should better understand how pain works by examining other factors that influence neck pain. These would include genetics and the immune system.

For improving the alignment of the neck, the evidence support seems to be weak. A joint study published in 2020 from Danish and Iranian researchers found that there are “some positive effects” of exercise. However, the quality of the 22 randomized controlled trials were quite “poor.” Using the assessment quality based on the Cochrane Review, most of the studies did not report how the subjects and researchers were blinded, how was the trial randomized, and other factors that rank the quality to be “low” to “moderate.”

The researcher cited a previous 2018 systematic review on the effects of exercise for forward head posture where therapeutic exercise for improving cervical lordosis is effective. However, there is no established relationship between forward head posture and neck pain, which questions whether some patients should even invest their time and energy with “correcting” their neck posture.

The premises behind the posture-correction exercises are based on “Janda’s postural syndromes,” which basically says that certain muscles in the body get shortened or tight while their opposing groups are lengthened or inhibited. These syndromes are commonly known as “lower cross syndrome” and “upper cross syndrome.” Although these syndromes are quite popular among manual therapy and fitness professions, research has not validated these ideas.

In other research about other types of posture, current evidence indicates that strength training may be better for changing both kyphotic and lordotic curves, but the amount of change in the latter is too small to have any significance, according to a 2019 systematic review and meta-analysis. The researchers indicated that one major drawback is that the included studies had mixed designs and different populations, which does not give a consensus on treatment effectiveness and for whom certain exercises are for. Therefore, clinicians should not put a “one-size-fits-all” mentality to exercise recommendations for every patient.

Overall, the review recommends strength training two to three times a week for eight to twelve weeks to see any improvements in spinal curvatures.

Although there are no specific exercises that you should follow to the rule, you can still explore different exercises to see which ones work for you. If you are unsure about how to do some of these exercises correctly and safely, consult with a physical therapist or qualified personal trainer.

Should I still learn how to fix cervical lordosis? 

Given the existing evidence and complexity of pain, it is difficult to answer in a broad sense. There are many factors that contribute to the pain experience, and there is no recipe to treat different types of neck pain. The best way to determine whether you should “fix” your cervical lordosis or not would be to consult with your physician, physical therapist, or another qualified healthcare professional. They can evaluate your health history, examine your condition, and determine the best approach to treat your neck pain for your unique needs.

While posture can affect your pain experience, it is only one piece of the bigger puzzle of pain. As for my chronic neck pain, I may have done myself a favor by discontinuing treatment and focusing on other activities and habits that can improve my condition. I don’t think my cervical lordosis is that much different now than seven years ago. Given the evidence about how pain works, I no longer rely on the idea of “posture equals to pain” as my narrative.

 

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A native of San Diego for nearly 40 years, Nick Ng is the founder and editor of Massage & Fitness Magazine, an online publication for curious massage therapists and the public who want to explore the science behind touch, pain, and exercise, and how to apply that in their hands-on practice or daily lives.

An alumni from San Diego State University with a B.A. in Graphic Communications, Nick also completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014. Prior to entering the massage profession, he also had worked as a personal trainer for 14 years.