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What to do if you already have back pain

What’s The Best Sleeping Position? The Answer Might Surprise You

What’s The Best Sleeping Position? The Answer Might Surprise You 2560 1709 ResilientRx

When it comes to sleeping and pain, I often have been asked questions like, “what’s the best pillow for neck pain?” Or “is sleeping on my stomach bad for my low back?” Unfortunately, there is no single answer, as each person’s circumstances will be vastly different, even with the exact same pain issue. There’s a lot of conflicting information out there, so I hope this blog can give some insight.

Should You Avoid Certain Positions?

We don’t want to underestimate the importance of sleep in our health. We know that poor sleep, especially chronically, can have significant health impacts on things like pain, injury risk, and performance. Such questions like the ones listed above are valid and need to be answered honestly by the healthcare community.

You may have heard advice like sleeping on your stomach is bad for your neck or back from friends, family, or even healthcare providers. While positions like this can be uncomfortable for many people, it is not an inherently bad position and is too much of a generalization to apply to all human beings. This is due to the simple fact that pain is such a multi-factorial, individualized experience. Not to mention that preferred sleeping positions are also influenced by things like age, health conditions, and body mass. 

In my nearly 11+ years of clinical experience, I have observed such variety of positions that both help or exacerbate people’s pain. For example, one person reports that switching from their side to back-sleeping helped their pain, while the next person found the exact opposite to be true. Again, we simply can and should not paint with such broad strokes and say X is bad and Y is good. There’s even research that suggests that there is no association between things like shoulder or spine-related pain and sleeping position (Cary, et al, 2016 & Holdaway, et al, 2018).

Should you sleep in Neutral Spine

Sleeping With a Neutral Spine Is Good, Right?

Have you tried sleeping with a pillow between your knees to maintain a “neutral spine,” but almost NEVER seem to wake up with it in the same spot? That’s because we naturally change positions frequently throughout the night. Studies have reported that we can change positions upwards of 19 to 32 times per night! (De Konick, et al, 1992, and Kubota, et al, 2003).

Additionally, we know that neutral spine is not one position, but a range. If sleeping with a neutral spine helps you sleep better or perhaps with less pain, that’s great! But there will inevitably be others that will sleep better or have decreased pain when not in spinal neutral. And that is okay too!

What to do if you already have back pain

What to Do if You Already Have Pain

Aside from all of the things you could be doing during your waking hours to help with pain (we’ll save that for another blog), there may be certain positions that you may want to temporarily avoid. For example, if you have shoulder pain, you may want to sleep on the opposite side and hug a pillow close to support your injured shoulder. If you have a lower back or neck problem, sleeping on your stomach may be irritating because you are laying in pain-provoking positions for longer periods of time than your tissue will tolerate.

Making positional adjustments like laying on your back or using pillows may help you get more restful sleep. This does not mean you should not or could not go back to sleeping in those other positions.

Waking up refreshed


  • There’s currently not enough evidence to conclude that certain sleep positions are better or worse for musculoskeletal problems such as neck, shoulder, or back pain.
  • Some research supports that there is no causal link between sleeping positions and risk for developing pain.
  • If you feel like you’ve “slept wrong” and now have pain, it’s more like a matter of what you’ve been doing (or not doing) during your waking hours the preceding days/weeks/months. In other words, you are doing too much or too little of movements or activities which contributes more to your pain experience than simply how you are positioned in bed.
  • Quality and quantity of sleep matter more than specific positions. If you’ve been told that certain position(s) are harmful, but they still feel comfortable to you, IT’S OKAY TO SLEEP IN THOSE POSITIONS.
  • I’m NOT saying position NEVER matters. Certain postures can influence pain, but we should not create fear-based narratives around how people sleep (i.e. you will have pain or be misaligned if you sleep on your stomach)
  • Temporarily changing positions or utilizing certain postures (i.e. propping with pillows) can be helpful during an episode of pain
  • You may have to experiment and find the right combination of pillow or mattress type right for you. Unfortunately, there is not one solution that will be best for everyone. That’s where guidance from your physical therapist can help!


De Koninck, J., Lorrain, D., & Gagnon, P. (1992). Sleep positions and position shifts in five age groups: an ontogenetic picture. Sleep, 15(2), 143-149.

Kubota, T., Ohshima, N., Kunisawa, N., Murayama, R., Okano, S., & MORI‐OKAMOTO, J. (2003). Characteristic features of the nocturnal sleeping posture of healthy men. Sleep and Biological Rhythms, 1(2), 183-185.

Cary, D., Collinson, R., Sterling, M., & Briffa, K. (2016). Examining the relationship between sleep posture and morning spinal symptoms in the habitual environment using infrared cameras. Journal of Sleep Disorders: Treatment & Care.

Holdaway, L. A., Hegmann, K. T., Thiese, M. S., & Kapellusch, J. (2018). Is sleep position associated with glenohumeral shoulder pain and rotator cuff tendinopathy: a cross-sectional study. BMC Musculoskeletal Disorders, 19(1), 1-8.


Sleep and Athletic Performance

Sleep and Athletic Performance 1200 799 ResilientRx

Quality sleep is an important consideration when it comes to pain, injury and recovering after a workout. Research supports that individuals who get a bad night’s sleep (especially those with chronic sleep issues, insomnia, etc.) are more likely to have pain the subsequent day. In fact, two thirds of people with chronic pain suffer from sleep disturbances.

Sleep influences our pain experience and internal function.

Studies suggest that disturbances in sleep may hinder key physiological processes in the body that contribute to the development and maintenance of chronic pain, including your body’s ability to inhibit or regulate pain. A recent review showed the role poor sleep patterns can play in causing acute injury to transitioning into chronic pain in adolescents. Many of the substances in our bodies that help regulate our sleep-wake cycles such as serotonin also regulate pain signals (Andreucci, et. al, 2021). So if we constantly are in a depleted state due to lack of sleep, this can disrupt the balance of these processes in our bodies and therefore lead to persistent pain and inability to recover from an injury in a reasonable amount of time.

Poor sleep, especially over time, can also have negative impacts on things like cognitive function, emotions, immune function, energy conservation and synthesis, immune function, and cardiovascular health (Wei, et. al., 2019).

Injury Risk in the Athletic Population

Even for patients without chronic pain, the risk for overuse injury increases with lack of quality sleep. A recent 2020 study showed that less than 7 hours of sleep led to an increased injury risk in endurance athletes (Johnston, et. al., 2020). They found that there was a 2 week delay from the period of poor sleep to the time of the new injury!

Oliver, et. al. in 2009 found that for athletes with 30 hours of total sleep deprivation, they experienced a 2.9% decrease in running performance. Another study looked at 2 groups of endurance athletes performing a stationary cycle test to failure. One group had normal sleep and the other group was sleep-deprived. The athletes in the sleep-deprived group showed a 9% reduction in endurance (Temesi, et. al., 2013).

How about effects on weightlifting performance? One study showed that limited sleep to 3 hours per night for just 2 nights, reduced lifting performance in multiple upper and lower body exercises (Reilly & Piercy, 1994). Other important factors such as motor control, coordination, and athletic response time have also been shown to be negatively impacted due to lack of quality sleep, all of which can lead to injury (Mah, et. al., 2019).

The take-home message for the above examples is that with poor sleep not only are you at increased risk for injury, but your athletic performance will suffer.

Adequate sleep can increase athletic performance.

A great example of what consistently good sleep can do for you can be found in Stanford’s men’s basketball team. The players participated in a 2011 study by Mah, et. al. where they increased their sleep an average of 2 hours per night for 5-7 weeks, with the goal of getting about 10 hours of sleep per night. As a result, the team saw a 10% increase in sprint performance and 9% increase in 3-point and free-throw accuracy!

Helpful Sleep Tips
  1. Go to bed and wake up at the same times every day
  2. Go to bed and wake up at the same times every day
  3. Keep your bedroom dark and cool
  4. Limit screen time – no cell phone or TV 30-60 minutes prior to bed
  5. Keep caffeine intake to early in the day
  6. Meditation/mindfulness practices

If you are struggling with pain or an injury, physical therapy can help! We can evaluate your movement, strength, and function and come up with a plan to help get you out of pain and back to doing what you love!

Written by Nick DiSarro, PT, DPT, OCS

Sources: Wei, Y., Blanken T.F., Van Someren. Insomnia really hurts: Effect of a bad night’s sleep on pain increases with insomnia severity. Retrieved from https://pubmed.ncbi.nlm.nih.gov/30210367/

Finan, P., Goodin, B., & Smith, M. (2013, December). The association of sleep and pain: An update and a path forward. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046588/

Johnston, R., Cahalan, R., Bonnett, L., Maguire, M., Glasgow, P., Madigan, S., . . . Comyns, T. (2019, November 01). General health complaints and sleep associated with new injury within an endurance sporting population: A prospective study. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S1440244018308545

Oliver, S. J., Costa, R. J., Laing, S. J., Bilzon, J. L., & Walsh, N. P. (2009). One night of sleep deprivation decreases treadmill endurance performance. European journal of applied physiology, 107(2), 155-161.


Andreucci, A., Groenewald, C. B., Rathleff, M. S., & Palermo, T. M. (2021). The Role of Sleep in the Transition from Acute to Chronic Musculoskeletal Pain in Youth—A Narrative Review. Children, 8(3), 241.


Temesi, J., Arnal, P. J., Davranche, K., Bonnefoy, R., Levy, P., Verges, S., & Millet, G. Y. (2013). Does central fatigue explain reduced cycling after complete sleep deprivation. Med Sci Sports Exerc, 45(12), 2243-53. http://karen.davranche.free.fr/pub/Temesi,%20Arnal,%20Davranche_et_al_MSSE_2013.pdf

Reilly, T., & Piercy, M. (1994). The effect of partial sleep deprivation on weight-lifting performance. Ergonomics, 37(1), 107-115. https://pubmed.ncbi.nlm.nih.gov/8112265/

Mah, C. D., Sparks, A. J., Samaan, M. A., Souza, R. B., & Luke, A. (2019). Sleep restriction impairs maximal jump performance and joint coordination in elite athletes. Journal of sports sciences, 37(17), 1981-1988. https://pubmed.ncbi.nlm.nih.gov/31122131/

Mah, C. D., Mah, K. E., Kezirian, E. J., & Dement, W. C. (2011). The effects of sleep extension on the athletic performance of collegiate basketball players. Sleep, 34(7), 943-950. https://academic.oup.com/sleep/article/34/7/943/2596050?TB_iframe=true&width=370.8&height=658.8

Sleep for Rehab; YouTube video presentation by E3Rehab https://www.youtube.com/watch?v=OAaAnWB-3jY