Lordosis in the concave curvature of the spine, and it often refers to the lumbar spine. Colloquially called “swayback,” it can also refer to the neck curvature—known as cervical lordosis—which is related to forward head posture and upper cross syndrome.
Lumbar lordosis and cervical lordosis are often blamed for back pain and neck pain, respectively, causing many people to likely seek treatment to reduce the lordotic curve which they believe to be the primary cause of pain—via exercise, surgery, or another intervention. However, whether this treatment approach works or not is questionable since scientific research on low back pain, neck pain, and the pain experience itself reveal something about the relationship between lordosis and pain.
What causes lordosis?
Cervical and lumbar lordosis are thought to be caused by some common factors, such as spondylolisthesis (a vertebra “slips” forward onto the bone directly below it), obesity, osteoporosis, and discitis (inflammation of the space between vertebral discs). However, research has shown that these factors do not always predict whether someone has back or neck pain because of them.
Some researchers found that obesity may affect the degree of the lordotic curve, including children, by increased pressure on the lumbar facets and weight shift to the front of the body because of excessive belly fat.
For some people, however, lumbar lordosis may be an adaptation to pain rather than a “cause” of pain, a compensation to maintain balance in the sagittal plane. This is what was found in a 2020 study from Abant Izzet Baysal University in Bolu, Turkey. The researchers compared 50 subjects with spondylolisthesis and 75 without and found that pelvic tilts, lordotic angle, and sacral slope are higher among those with the condition.
But this does not mean that lordosis causes spondylolisthesis. By studying previous research on this topic and pooling their data, they concluded that lordosis “may be a compensation mechanism developed by patients to reduce pain and maintain the sagittal balance.”
The association between osteoporosis and the degree of lumbar lordosis is weak. A 2008 Greek study of 112 women compared those with either osteoporosis, osteoarthritis, or both diseases with healthy controls. The researchers do not find significant differences of lordotic curves among all the women.
Another study in 2013 of more than 250 women found a weak, but significant, association between lumbar lordosis with bone mineral density. However, the risk of osteoporosis in the thoracic spine appears to be great among post-menopausal women with kyphosis.
Discitis, which affects mainly in toddlers and children, seems to negatively correlate with the degree of lumbar lordosis. Symptoms include refusal to walk, back pain, loss of lumbar lordosis, and inability to flex the lower back. The lack of lordosis may be also an adaptation to reduce pain.
Contrary to lumbar lordosis, the lack of cervical lordosis is often blamed for most types of neck pain—including text neck and upper cross syndrome. However, most of the research on neck posture and neck pain find a weak association between the two.
A 2017 study from the Università degli Studi di Siena in Siena, Italy, found that neck posture is poorly associated with various cervical spine disorders and diseases, such as disk protrusions, stenosis, and spondylosis. The researchers 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.
A large cross-sectional study from Curtin University in Western Australia of more than 1,100 teens found no relationship among neck posture, headaches, and neck pain. They found that teens with a forward head posture or slumped posture were more likely to have depression, while those who have a more upright neck posture do regular exercise or physical activities. Thus, 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.”
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.
Types of lordosis
Lumbar lordosis is classified into four types, which is based on three points of measurement:
- Pelvic incidence: angle between the line perpendicular to the middle of the sacral endplate and a line from this point to the center of the femoral head.”
- Pelvic tilt: angle between a vertical line from the center of the femoral head and a line from the same point to the middle of the upper endplate of S1.
- Sacral slope: angle between the upper endplate of S1 and a horizontal line.
In type 1 lordosis, the sacral slope is less than 35 degrees with the top of the lordosis starting at L5. This is where the lumbar spine appears to be flat, but it still has a small degree of lordotic curve. Sometimes the thoracic spine is hunched, similar to the associations with posterior pelvic tilt
In type 2 lordosis, the sacral slope is less than 35 degrees like type 1, but the lordotic curve begins at L4. People with this type usually appear to lack curves on the upper and lower spine.
In type 3 lordosis, the sacral slope is between 35 to 45 degrees. The curve begins in L4 and the lordosis tilt angle is almost zero. This is considered a “neutral” spine.
In type 4 lordosis, the sacral slope is greater than 45 where the curve begins in L3 or higher. This is considered to be hyperlordosis and is often a characteristic of anterior pelvic tilt.
This classification system is also known as the Roussouly Classification, named after the French researcher Pierre Roussouly who published a paper in 2005 that examined the different types of lordotic postures from 160 asymptomatic subjects.
While this system is popular among clinicians and researchers, some question whether this is a valid way to consider what range is “normal” and what is not for certain diseases or disorders.
For example, a 2013 review of 120 studies found that such as age, gender, body mass index, ethnicity, and sport, “may affect the lordosis angle, making it difficult to determine uniform normal values.” They emphasized 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.
As mentioned before, there is a weak association between the degree of lumbar lordosis and low back pain. However, some people with excessive lordosis may find some pain relief from exercises that target the lumbar and pelvic region.
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. One major drawback in the study, the researchers indicated, is that the studies included had mixed designs and different populations. Therefore, clinicians should not draw a “one-size-fits-all” mentality to exercise recommendations.
Generally speaking, the review recommends strength training two to three times a week for eight to twelve weeks to see any improvements in spinal curvatures.
Sample exercises include:
Ball reverse hip extension
Glute bridges, pelvic thrusts
Although both exercises can help reduce the lordotic curve, they also help develop strength and power in your glutes. Personal trainer Sohee Lee demonstrates the differences.
Deadlifts target your glutes as well as strengthening your torso. Nick Tumminello offers tips for non-athletes and non-powerlifters to do a basic deadlift.
For some people with low back pain, this may be an advanced level of strength training. You should have adequate lower back strength and endurance before attempting this exercise. Be sure to check with your physical therapist or qualified personal trainer.
For back pain relief, almost any kind of exercise would work, and none are “better” than another. The types of exercises and activities that you do should be something that you enjoy and can do consistently.
Although there are no specific exercises that should be followed to the rule, you can still explore different exercises to see which works for you. If you are unsure about how to do some of these exercises correctly and safely, consult with a qualified personal trainer or physical therapist with a strong background in sports medicine.
Should I still learn how to fix lordosis?
Because pain is a multi-dimensional experience, blaming any single factor, like lower cross syndrome, as a source of pain can be an erroneous thinking process. You can miss out other factors that may also contribute to your pain, such as lack of sleep, stress, anxiety, and not enough exercise.
While posture, like scoliosis, rounded shoulders, and leg-length discrepancy, can affect your pain experience, it is usually not a strong influence to pain, as indicated in the current scientific evidence. Keep in mind that every person’s pain experience is unique and there is no cookie-cutter type of treatment or narrative for everyone.
Always consult a qualified medical professional should you have severe low back pain that prevents you from doing your work, sleep, or daily activities.
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A native of San Diego for nearly 40 years, Nick Ng is an editor of Massage & Fitness Magazine, an online publication for manual 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.
When he is not writing or reading, you would likely find him weightlifting at the gym, salsa dancing, or exploring new areas to walk and eat around Southern California.