Sleep. Love it or hate it, we all need it. But did you know that your sleep positions could be causing you pain and robbing you of your precious sleep?
Does the position really make such a big difference?
Sleep position, like posture, has an ideal where the least amount of pressure is placed on the structures of the spine and muscles. This is something that can be corrected and practiced. But also like posture, habits are hard to break.
The three areas mostly impacted by your sleeping position are the lower back/pelvis, neck and shoulders.
A study done by physiotherapists in Australia(1), found that sleep position had a significant impact on the prevalence of neck and thoracic (mid-back) pain during the waking hours. So let us take a look at the most common sleeping positions and how they could be harming you.
Most common sleep positions
1. The Supine position (lying on the back)
- Arms by side
- Arms across chest
- One hand on forehead
Lying supine is one of the most supported positions for your lower back. However, if you have a hollow back (increased lumbar curvature) due to tight hip flexor muscles or struggling with a disc bulge, this can be a very painful position to stay in. A pillow under the knees, will make this a more comfortable position to sleep in.
A study (2) conducted on the activity of neck muscles during the sleeping hours, concluded that sleeping with one hand on your forehead increases the activity of the scalene and upper trapezius muscles. This was due to the position of the shoulder needing scapular (shoulder blade) as well as clavicular (collar bone) movement to attain the position. These two muscles are notorious for creating headaches, arm pain and neck stiffness.
Any arm position that requires the scapula and clavicle to change position will result in this tension, so it is best to avoid having the arms out to the sides at angles larger than 45 degrees e.g. arm behind the head and hand on forehead as mentioned above.
The study concluded that arms across the chest and arms by your side at an angle less than the 45 degrees reduces muscle tension.
Best option for supine…
2. The Side-lying position
- Full-foetal
- Semi-foetal
The full-foetal position which requires neck, back and hip flexion in excess, takes away all the natural adult curvatures which are perfectly balanced to place the least amount of pressure on the discs, ligaments and muscles of the back. The hyper curvature is similar to sitting on a couch or chair for 8 hours, not great for the discs or hips. It is better to adopt the semi-foetal position where the body is less curved, keeps the neck neutral and hips less flexed. Semi-foetal maintains the curves and a pillow between the knees helps keep the pelvis from twisting
What about the neck and shoulders? In order to make the side-lying position optimal for the neck and shoulders, a pillow is generally needed. This is best done by filling the gap between the head, shoulders and the bed.
Two separate studies concluded that poor pillow choice results in pain and poor quality of sleep. Gordon et al (3) looked at self-reported comfort and reduced pain on waking. A latex pillow was reported as less pain on waking than foam, contour foam or a feather pillow. Jeon et al (4) found that an orthopedic pillow was superior in providing good positioning, less symptoms and later, after adjusting to the pillow, even comfort.
In my practice I have noticed that regardless of pillow, a common position that results in neck pain is when it is flexed forward and the ear almost tucked into the shoulder. As mentioned above with shoulder position, this position increases the tension in the scalenes, upper trapezius, shoulder elevator and cervical rotation muscles. A good pillow can help but it also requires the user to become aware of their neck position and to take it back somewhat.
Head back, not tucked forward
Best option for side-lying…
Pillow between knees, hug a pillow and head on latex/rubber pillow
Head supported on latex/rubber pillow
3. The Prone position (lying on the stomach)
- Neck to one side
- Neck to one side with same side hip flexed
The prone position or lying on your tummy is a fantastic position for disc pain if the bed isn’t too soft. If you have neck or joint problems, prone is a terrible idea as a rotated neck will place great strain on the joint surfaces between the vertebrae (neck bones) especially for prolonged periods. This position is even worse if the one leg is pulled up to the same side. Once again the joint surfaces of the hip get compressed and can result in reduced hip mobility and degeneration over time.
Prone position placing pressure on neck and hip.
Best option for prone if you have to…
Pillow under the hips.
So what is the best position?
The winner is semi-foetal side-lying as seen in the best position for side-lying.
Gordon et al (1) concluded that people were less likely to report waking symptoms such as neck pain if they slept on their side.
This position can further be improved with an orthopedic pillow for the neck as well as one between the knees. The recommendation for the neck is a rubber or latex pillow. It is superior to a foam contour pillow regardless of the shape. Feather is not recommended.
Most common recommendations:
The other positions can be somewhat improved with good habits and pillows but these are best discussed with your personal physiotherapist who knows your underlying conditions.
| Painful area | Best sleep position | Equipment |
| Hip | Supine | Pillow under knees |
| Lower back pain | Side-lying or;
Supine |
Pillow between knees
Pillow under knees |
| Neck pain | Side-lying
Supine with arms by side or across chest |
With orthopedic/latex pillow
|
| Shoulder pain | Supine with arms by side or across chest
Side-lying |
With orthopedic/latex pillow and hug another pillow, painful shoulder on top |
References
- Gordon S, Grimmer K, Trott P. Sleep position, age, gender, sleep quality and waking cervico-thoracic symptoms. The internet journal of allied health sciences and practice. Jan 2007, Vol 5, number 1.
- Gordon S, Grimmer K, Trott P. Pillow use: the behavior of cervical pain, sleep quality and pillow comfort in side sleepers. Manual Therapy., 14, 671-678.
- Jeon MY, Jeong H, Lee S, Choi W, Park TH, Tak SJ, Choi DH, Yim J. Improving the quality of sleep with an optimal pillow: a randomized, comparative study. Tohoku J Exp Med 2014 Jul;233(3):183-8.
- Won-Hwee Lee and Min-Seok Ko .Effect of sleep posture on neck muscle activity. J Phys Ther 2017 Jun; 29(6): 1021–1024.