Best Sleeping Positions to Avoid Back Pain

You can also listen to this in the Back Talking Podcast here!

In my last post, I discussed the best type of mattress and pillow you should be sleeping on. There are many options out there when it comes to mattresses. Firm, soft, pillow tops, sleep number, temper-pedic foam, and I’m not even sure if they still sell water beds, but I’m sure there are some out there. There isn’t much research out there that applied to this topic, but there were 2 very good pieces of research in the literature. The first dealt with sleeping on a firm vs medium firm mattresses, the second dealt with the age of and the quality of  (more importantly known as cost), of the mattress.

The recommendation for those suffering from back pain was, for years, a firm mattress, and if that mattress wasn’t firm enough, throw a piece of plywood under the mattress to help stiffen it up. Well that recommendation has been thrown out the window with the first research article, they found that those who suffered from chronic lower back pain fared better sleeping on a medium-firm mattress. They had less pain while in bed, less pain upon arising, less disability due to back pain, and less day-time back pain, compared with those who slept on the firm mattress. The reasoning is that a medium-firm mattress helps support the body more evenly, maintains it’s proper neutral alignment, and doesn’t create pressure points. A mattress that is too firm can create pressure points in the shoulder, hip, and heel regions, or your heavier body parts, which can lead to pain in those regions. It’s almost like sleeping on the floor.  On the flip side, a mattress that is too soft doesn’t offer enough support to the spine, allowing the spine to be bent or twisted into awkward angles. This can place undo stress on joints, ligaments, tendons, and muscles which can cause injury to those structures.

The second study showed essentially that the newer a mattress is, and if it is of higher quality, the better someone feels upon arising. They found that the average age of the mattress when people were buying a new one was 9.5 years. Mattresses definitely have a lifespan, they begin to break down and lose the ability to support your body. And you kind of get what you pay for, the higher quality mattress ( meaning the more expensive ones) tended to afford the person a better night’s sleep.

But it doesn’t matter the surface that you are sleeping on, what is most important is, the position that you sleep in. So what am I talking about? The best position to sleep in is one that keeps your spine in a neutral posture, and there are 2 positions that can accomplish this. What is neutral posture you say? When someone is standing, balanced evenly on both legs, looking at them from the side, there is a normal forward curve in our lower back, there is a backward curve to our midback, and our neck, if you could see inside of it, should have a forward curve to it as well. This is the neutral spine position. It is not flexed forward, nor extended backward, or flexed to the side, or rotated at all.

So the best position to sleep in is on our back. When we lie on our backs we are in a neutral spine posture, provided that you don’t have a stack of pillows under your head so that your chin is touching your chest. And from the last episode, we discussed that back sleepers should be using a contoured pillow, one that has a hump in the front to help support the neck, and an indentation in the middle to help support the head. But not everyone feels comfortable on their back, or they snore at decibel levels that rival a jet engine on takeoff.

Sleeping on your side is acceptable as well, with some pointers. Again we need to maintain that neutral posture. We should be able to draw a straight line from top of your head, through your nose, center of your chest and your pelvis. What gets people in trouble is that they like to flop the top leg over the bottom leg, essentially twisting the bottom half of their body. When we do that we place our lower back into rotation, which is a no-no. This again places the discs, ligaments, joints, muscles and tendons into a position of stress which could cause them injury. This may explain why you may wake up in the morning stiff and sore. Finally, when sleeping on your side, the pillow should be thick enough to fill the gap between the mattress and our ear, to again keep our neck in a neutral posture.

So you should get the point by now, it’s all about maintaining a neutral posture where your spine is not bent, flexed or rotated. Back sleeping is best, but side sleeping is acceptable as well.

Best Mattress and Pillow for Back Pain

To listen to this episode on the Back Talking podcast, click here

“Do you know what is the best mattress for back pain?” or “What type of pillow should I be sleeping on?”  These questions have to rank in the top 5 questions that have ever been asked of me, all time. Now scanning the literature, there isn’t a lot of research that has been conducted on mattresses or pillows, so sign me up if anyone would like to send me a mattress or pillow to conduct research on!

Back pain is one of the top reasons that people start to lose mobility in middle age. Pain interferes with engaging in physical activities, which then can lead to the downward spiral of weight gain, loss of strength, endurance, and balance. Considering that we spend about ⅓ of our day or life in bed, choosing the right mattress and pillow is essential for preventing or managing back pain.

Old school recommendations for those suffering from back pain was a hard or firm mattress. If it wasn’t firm enough, throw a piece of plywood under the mattress, or better yet, sleep on the floor! Yikes!

A 2003 study published in the medical journal Lancet, took a look at 313 adults with chronic low back pain. They were split into 2 groups, with one group sleeping on a hard or firm mattress, and the second group on a medium firm mattress for 90 days. They were asked to rate their pain levels while in bed and upon arising from bed. Those who slept on the medium firm mattress reported less pain while in bed, less pain upon arising, less disability due to back pain, and less day-time back pain, compared with those who slept on the firm mattress.

The rationale behind a medium-firm mattress is that it distributes the pressure more evenly across the body, and helps avoid too much weight being carried by heavier body parts such as the head, shoulders, and hips. This can create pressure points that can become sore. You want the body to have more contact with the mattress. So your next thought would be, well that sounds like a soft mattress would be even better. Well a mattress that is too soft is just as bad as one that is too firm. It allows you to sink in too much and doesn’t provide enough support for the spine, it doesn’t keep your body in a neutral posture or  in alignment. So you’re more likely to wake up stiff and sore.

A second study published in 2008 in the journal of Applied Ergonomics, showed that the age of and the quality of the mattress had a major effect on back pain. People sleeping in new beds had significantly less pain and more comfort than when they were sleeping on their older mattresses. They found that the average age of mattresses people were sleeping on before getting a new mattress was 9.5 years! Also, you get what you pay for, for the cheapest category of beds, low back pain was significantly more prominent than for medium and higher priced mattresses.

One last piece of advice regarding mattresses. You know that tag on the mattress that says “removal of this tag is punishable by death” or something like that, you should write on the tag the date of purchase of the mattress. You’d be surprised how poor your memory is when it comes time to remembering when you bought that mattress.Your mattress is probably older than you think! Also, if you ever need to file a warranty claim, you’ll need that tag to still be attached to the mattress otherwise it voids the warranty.

Just as with your mattress, you spend a ⅓ of your day/life with your pillow, so choosing the right pillow can also mean the difference between getting a good night sleep or awakening stiff, sore, and in pain. Some causes of neck pain are beyond our control such as the degenerative aging process, but we can do other things to help minimize the risk. One place is to look at is, how we sleep, and what effect this may have on neck pain and the type of pillow to use.

The position that we sleep in (the majority of the time) ultimately decides the type of pillow that we should use. Now the function of a pillow is two-fold; one to keep us in proper position or neutral alignment, and second to provide comfort.

Now a quick note on what is proper neutral alignment. To review, the spine has a natural forward curve in the neck region when viewed from the side. That is the neck or cervical regions neutral alignment. It is not flexed, rotated, or bent to the side. If you have a pillow that places you into an awkward spinal angle, it can place abnormal stress on the muscles, ligaments and joints of the neck and shoulder area.

2 sleeping positions are easiest on the neck; on your side or on your back. If you are a back sleeper, choose a thinner pillow to avoid flexing your neck forward. What works best are the contoured pillows that have a hump in the front to help support your neck, and then an indention for your head to rest in. If you are a side sleeper, choose a firmer pillow that is thick enough to fill the gap between your ear and the mattress, while keeping your neck in a straight line with your body.

A final note, sleeping on your stomach is rough on your spine because your back is arched and your neck is turned to the side to breathe. I always tell people to imagine sitting in a chair with your head turned to the side for 8 hours, how do you think your neck will feel? not very good after having one side stretched and the other side jammed all day.

The NSAID Safety Oxymoron

You’ve heard me discuss the failure of the medical model when it comes to back pain. The typical scenario is that you present to your doctor’s office with back pain, and you walk out with a prescription for a muscle relaxer and pain killer, probably an NSAID. Well, how has that model worked for us? Hmm let’s see, the recurrence rate for back pain is 50% every year. Well that’s not very successful now is it? That is the very definition of medical mismanagement.

In 2005, the FDA issued a warning that taking nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen increased the risk of having a heart attack or stroke. Just this month, July 2015, it took the unusual step of further strengthening this warning. This was done on the advice of an expert panel that reviewed new information about NSAIDs and their risks. Because NSAIDs are widely used, and of the public’s general perception of their safety, it’s important to be aware of downsides of taking an NSAID. You’d be surprised at the number of people that eat them like M&M’s.

Now the term NSAID may confusing to you. Examples of commonly used over-the-counter NSAIDs include ibuprofen, more commonly known as motrin or Advil or Motrin, and naproxen, more commonly known as Aleve.  Celecoxib (Celebrex), diclofenac (Voltaren) are prescription NSAIDs. Now many people take NSAIDs to relieve mild to moderate pain. In fact, the sales totals of Advil, Motrin, and Aleve alone top out at over 1 billion dollars a year. These medications are particularly effective in conditions in which pain results primarily from inflammation, such as an injury. Acetaminophen, more commonly know as Tylenol, is not a NSAID, and as we talked about in the last episode, has not been found to be effective for back pain sufferers so don’t waste your time with it. Aspirin is an NSAID, but it does not pose a risk of heart attack or stroke and is not covered by this new warning. But aspirin has it’s own set of risks, most importantly GI bleeding.

For more than 15 years, experts have known that NSAIDs increase the risk of heart attack and stroke. They may also elevate blood pressure and cause heart failure. The risk of heart attack and stroke achieved special notoriety with rofecoxib (Vioxx). It caused as many as 140,000 heart attacks in the U.S, and an estimated 55,000 deaths during the five years it was on the market (Vioxx was removed from the market in 2004). The manufacturer of vioxx, Merck, has settled lawsuits to the sum of $4.85 billion dollars surrounding this drug.

The experience with Vioxx raised awareness about the safety of NSAIDs, and led to further studies showing that the risk is not limited to Vioxx, but is associated with all NSAIDs.

The new warnings from the FDA point out:

  • Heart attack and stroke risk increase even with short-term use, and the risk may begin within a few weeks of starting to take an NSAID.
  • The risk increases with higher doses of NSAIDs taken for longer periods of time.
  • The risk is greatest for people who already have heart disease, though even people without heart disease may be at risk.
  • Previous studies have suggested that naproxen or Aleve may be safer than other types of NSAIDs, but the new evidence reviewed by the expert panel isn’t solid enough to determine that for certain.

Taking an NSAID for back pain, or for a few days to ease a sore knee isn’t likely to cause a heart attack or stroke. It’s more prolonged use that can get risky.

In view of the new warnings, it is best for people with heart disease to avoid NSAIDs if at all possible, and for everyone who is considering taking an NSAID to proceed with caution. Here are some strategies:

  • It’s important to take the lowest effective dose, and limit the length of time you take the drug.
  • Never take more than one type of NSAID at a time. There appears to be risk associated with all types of NSAIDs.
  • Try alternatives to NSAIDs such as ice! It relieves pain and swelling and does not appear to increase heart attack or stroke risk.
  • If nothing else works and you need to take an NSAID for arthritis or other chronic pain, try taking week-long “holidays” from them.
  • If you experience chest pain, shortness of breath, or sudden weakness or difficulty speaking while taking an NSAID, seek medical help immediately.