Lordosis: Defect or Defense?

For anyone who has studied manual therapy for a long time, the role of lordosis and back pain has seen some interesting changes in perception. Before we explore this, I want to make a greater point: Treatment approaches are often based on philosophy rather than fact. The role of lordosis and back pain is a great example.

In 1937, Dr. Paul Williams taught a series of corrective exercises to counteract lordosis, which he perceived to be the cause of low back pain. He believed that lordosis had an effect on degeneration of both the spine and the discs. For those therapists who studied some form of early neuromuscular training based on the work of Raymond Nimmo, much of Nimmo’s low back treatment was geared to reducing lordosis.  Many therapy approaches wanted to lengthen and elongate the spine, reducing the lumbar curve.

Over the last few years, new ways of thinking have changed the perception of the role of lordosis, especially in relationship to the discs. During lordosis, the nucleus is wedged forward, moving it away from the nerves which lie posteriorly. This is the basis for the McKenzie approach, used by physical therapists to treat discal issues in the spine. In essence, lordosis is the answer to disc problems, not the cause.

When I shared this during one seminar, one therapist remarked that this could not be true.

“Every person I have ever seen with disc problems has increased lordosis,” she remarked. “Every single person.”

I have no doubt that this is true, but not for the reason that she thought. When the disc is compromised and is compressing spinal nerves, lordotic postures will provide relief by moving the discal material anterior and away from the nerve. This is why back pain sufferers often carry a little pillow to insert behind the back to sustain lordosis. This is the only posture that is comfortable. Conversely, sitting in a soft chair that creates posterior rotation of the pelvis (and therefore less lordosis) is extremely uncomfortable for these people.

While every person the therapist saw had both lordosis and back pain, the lordosis was a response to the pain, not the cause of the pain. She mistook defense for defect.

Obviously, there is a point at which too much lordosis is a problem.  There has to be a balance, but stating an ideal pelvic angle for everyone is a concept not supported by any data of which I am aware.  Anthropological studies of indigenous cultures reveal healthy (and seemingly exaggerated) lordotic curves, and lordotic curves are also clearly variable by culture and race. There is much yet to be known.

Most importantly, we have to be careful about linking two phenomena together as causative. We must always question whether what we observe is defense or defect. The more we question our assumptions, the better therapists we become.