Pain and Sleep

The process of sleep itself – including having the right mattress and pillow to support your sleeping position – is important for managing chronic musculoskeletal pain.

Research consistently finds that individuals with chronic pain experience significantly poorer sleep than those without pain. Worsened pain, combined with the effects of sleep deprivation, permeates all aspects of their lives, impacting their mood, relationships, and leisure activities. Over half of people with chronic pain report sleep difficulties interfering with their work.

In turn, chronic sleep issues can develop into chronic pain: a 2008 study of over 4,000 healthy volunteers found that the ones with sleeping problems were much likelier to develop chronic musculoskeletal pain within a year than those who regularly got good sleep.

While you sleep, your body restores and rehydrates your bone, cartilage, and muscle tissue, repairing the damage done during the day. In order for this process to complete, individuals need to cycle through their requisite amounts of sleep, especially deep sleep. However, chronic pain makes it challenging to be comfortable enough during the night to stay asleep, especially if paired with the wrong mattress, pillow, or sleeping position. These can all exacerbate pain, leading to sleep disturbances.

As a result, they are likelier to wake up, interrupting their deep sleep and the essential restorative process.

As a physical therapist, your guidance helps your patients live more pain-free lives. Individuals in physical therapy have health needs that extend beyond the physical therapy appointment. One of these areas is sleep. Helping your client sleep better reduces their pain, making it easier for them to stick to their treatment plan with you.

The following guide is meant to serve as a helpful resource for you as a physical therapist to reference when advising your patients on the best sleep positions, mattresses, and pillows for chronic or temporary pain.

Maintaining Proper Positioning and Alignment

The way a person positions themselves ergonomically in bed for sleep can either worsen or relieve their pain.

In order to avoid waking up with aches and pains, it’s essential that patients maintain spinal alignment (from your hips to your ears) while they sleep. Here’s how they can get their body into proper alignment based on their preferred sleep position.

Back sleepers may experience stress in the low back if it’s floating uncomfortably atop the mattress. To prevent this, place a pillow beneath the knees. If you sleep predominantly on your back, making sure you are not cocking your head to one side or the other will ensure you don't wake up with a stiff neck.

Side sleepers require a pillow that’s thick enough to keep the neck and head in neutral alignment with the spine. If one curls up too tightly in the fetal position, this can also increase strain on the back. Open up the curl, and place a pillow between the knees to reduce the stress on the low back and hips.

Stomach sleepers are most at risk of spinal strain and stress. This sleeping position requires one to turn their head to the left or right, twisting their spine out of alignment. Those living with pain should avoid sleeping on the stomach if possible and switch to the back or side.

However, if your patient can’t sleep unless they’re on your stomach, tell them to sleep with a very thin pillow, or no pillow at all, to keep the spine and neck as flat as possible. They could also place the thin pillow above their forehead. In order to maintain spinal alignment, consider a placing a thin pillow under the stomach. 

Use a pillow under knees when sleeping on your back.

Sleep with a pillow between your knees to keep the lower spine aligned.

Use a pillow under your abdomen when sleeping on your stomach.

For most of us, we don’t just get into bed and instantly fall asleep, especially if we are living with chronic pain. We often have to adjust and transition between a few positions before we’re comfortable enough to fall asleep. When they turn in bed, encourage your patient to aim to move the entire body as one unit rather than twisting or bending at the waist. Keep the abdomen pulled taut with the knees bent toward the chest – the smaller the surface area, the easier it will be to move. Moving as a unit prevents any unnecessary twists that can worsen pain.

Sleepers might also consider using a support roll. A support roll lies around your waist to low back and can help fill in the gaps between your lower back and the mattress surface, providing support and reducing pressure.

What Kind of Pain Do You Have? – Sleep Tips and Exercise Suggestions

Depending on the type of pain you have, the way you sleep could make you feel better, or a whole lot worse. Consider the following sleep tips and stretching exercise recommendations for your patients.

Low back pain

Most of the time, a torn muscle or strained ligament is the cause for temporary lower back pain. This can happen when you overstretch or strain your back repeatedly over time, as is the case with poor posture. Often, it happens because you picked up an object that was too heavy, and tried to adjust by suddenly twisting your back. Besides objects, sports injuries are another common contributor to lower back pain.

Common causes of chronic lower back pain include: lumbar herniated disc, degenerative disc disease, sacroiliac joint dysfunction, spinal stenosis, spondylolisthesis, scoliosis, or trauma from an accident.

The wrong mattress can also contribute to back pain. If the mattress is too firm, everything lies atop the surface without feeling supported, and the spine arches as a result. If the mattress is too soft, the shoulders and hips sink in too deeply and curve the spine out of alignment. Experts consistently recommend a medium-firm mattress is best for low back pain – it allows the pressure points to sink in just deeply enough so the spine can stay straight.

Stretching the lower back, buttocks, hamstrings, and core muscles can all help strengthen the back and so it can better support the weight of the body. Have your patients try the following exercises, starting with 20 to 30 second intervals:

  • Lie on your back. Then pull your knees to your chest and tilt your head forward.
  • Lie on your back with your knees bent and feet on the floor, and place your hands behind one knee. Alternate pulling one knee forward toward your chest.
  • Lie on your back with your knees bent and feet on the floor. Cross your right leg over your left with your right ankle on your left knee, making a number 4. Pull your left leg closer to your chest until you feel the stretch, then repeat on the other side.

Besides stretching, low-impact aerobics are another way to strengthen these muscles without putting extra stress on the spine. Try walking, water therapy, or elliptical, step, and stationary bike machines.

Mid back pain

Middle back pain describes pain in the thoracic spine, located beneath the neck and the bottom rib cage. Poor posture (such as slouching over a desk all day), obesity, and aging can all cause middle back pain. Traumatic events, such as a fall, fracture, muscle strain, or herniated disk are other common causes of mid back pain.

How can sleep worsen middle back pain? If you sleep on your back with a pillow that’s too high, you’re forcing your chin down into your chest, mimicking the kind of poor posture that leads to mid back pain.

The middle of your back can be tricky to stretch, but many yoga poses find a way to reach this area, such as:

  • Cat-Cow pose: Get on all fours and gently alternate between curling and arching your back, making concave or convex shapes
  • Passive backbend: Lie down on your back with a foam roller beneath your shoulders to open up your heart.

Pain in the upper back or shoulders

Upper back or shoulder pain can be caused by many of the same issues that contribute to back pain generally, such as poor posture, falls and trauma, and muscle sprains. But shoulder pain in particular can also be caused by a tear or inflammation in the shoulder tendons, a bone fracture,  arthritis or tendonitis. Tendinitis is a gradual process that happens from repetitive movements that strain the shoulder repeatedly over time.

If you sleep on your side, and sleep on the same side every night, that puts a lot of pressure on your rotator cuff and can lead to tendonitis over time. It cramps your arm and shoulder bones together, as well as the muscles and ligaments within those areas. To avoid this, advise patients to alternate which side they sleep on or sleep on their back occasionally.

Stretching exercises for relieving pain in the upper back or shoulders include:

  • To open up your rotator cuff, stand between an open doorway with your hands on either side of the doorframe just below shoulder height. Then lean forward until you feel a stretch.
  • Stretch your arms across your chest. Start with your left hand under your right elbow and pull your right arm across to the left. Then switch and repeat on the other side.
  • Do the CEO power stretch, but sitting straight up instead of leaning back in a chair. Clasp your arms behind your head for a nice upper back opener.

Neck pain

Neck pain may result from an injury like whiplash, temporary illness, or more serious conditions like a pinched nerve or degenerative disc disease.

The stomach sleeping position is notoriously bad for neck pain. However, even if you sleep on your side or back, you can experience neck pain if you have the wrong pillow or mattress combination. It’s key to find a pillow that’s just right and matches the length between the shoulder and the base of the neck. A pillow that is too high will tilt the chin downward for back sleepers, or the neck to the upper side for side sleepers.

Aerobic exercise generally helps the neck muscles stay strong and flexible. You can also have patients try the following neck strengthening exercises:

  • Sit cross-legged and gently pull your neck to one side with that hand. Repeat on the other side.
  • Sitting upright, place both hands behind your head and gently pull your head downward.

Hip pain

Hip pain can result from temporary conditions like injuries, fractures and tears, to more permanent conditions like arthritis, pinched nerves, bursitis, osteoarthritis, tendonitis, and sciatica-piriformis syndrome.

Your sleeping position and mattress can also contribute to hip pain. A too-firm mattress places pressure on the hips instead of relieving them by allowing them to sink into the mattress. On the other hand, with a too-soft mattress, the hips sink too deeply, causing strain.

Pregnant women commonly experience hip pain, since they’re suddenly carrying a lot more weight around that area. A pillow between the knees can help keep the hips and spine aligned.

Squats can help strengthen the hips, as can the following stretch:

  • Lie on your back with your knees bent and your feet on the floor. Squeeze and tighten your buttocks muscles, and release for several repetitions.
  • Then try this same exercise with lifting your hips off the ground and holding.


Fibromyalgia is one of the most common chronic pain disorders. It can run in families, be triggered by illnesses like arthritis and lupus or IBS, or occur as a result of physical or emotional trauma.

Because people with fibromyalgia have more sensitivity to noise and temperature, they can wake more easily during the night. Their pain also disturbs their sleep, leading to daytime fatigue. A mattress that’s loud, such as a springy innerspring, can wake them up, and any mattress that’s not supportive can worsen their pain. Foam and latex beds tend to provide the best relief for fibromyalgia sufferers, since they provide superior pressure point relief and motion isolation (absorbing noise).

Both walking and water therapy are low-impact forms of aerobic exercise that can alleviate the pain of fibromyalgia without causing soreness or stiffness afterwards.


Arthritis occurs when a joint is inflamed, creating extreme pain and stiffness that typically worsens over time. Age, bodily injury, and genetics are all risk factors for different types of arthritis.

The wrong mattress can worsen the pain arthritis sufferers feel during the daytime, and may even wake them up during the night, causing daytime fatigue. Like with fibromyalgia, memory foam and latex beds can provide relief due to their contouring abilities.

Regular exercise is especially important for arthritis sufferers, since it strengthens the bones and muscles around their joints. Exercise helps the muscles grow stronger; lack of exercise makes them stiff, weak, and more painful. Low-impact aerobic exercise is recommended since it’s easier on the joints, such as walking or using a stationary bike or elliptical machine. People with arthritis should switch the type of exercise in between days, to allow the muscles to rest and recover – such as light weight training one followed by aerobic exercise the next.

Mattress Considerations

Studies consistently show that sleeping on a high-quality mattress is critically important for individuals living with chronic back pain. The best bed for someone is one that provides sufficient support to keep the spine in natural alignment from the hips to the ears, while allowing it to maintain its natural C-shaped curve.

Three main factors determine the quality of a mattress and its suitability for individuals working with physical therapists: support, firmness, and pressure point relief.

Support and firmness

Support refers to the bed’s ability to support the spine’s natural alignment for the long term. A mattress that is old and has developed sags, for instance, can no longer provide proper support.

Firmness refers to how the bed responds to the sleeper’s body weight when they lie down on it. Doctors used to recommend firm mattresses for back pain relief, based more on opinion than any real evidence, but several recent studies have confirmed that a medium firm mattress is optimal. A 2003 study of individuals with chronic pain found that after a 90 day period, participants who slept on medium firm mattresses experienced significantly less disability and pain than those who slept on a firm mattress.

What about a soft mattress? These are dangerous for back pain sufferers as well.

  • With a mattress that is too soft, an individual who sleeps on their side will have their hips and shoulders sink in too deeply, causing the spine to arch as the stomach lies further up on the mattress.
  • A back sleeper will sink more deeply into a softer mattress, especially if they are overweight, creating a slouching position similar to poor posture.
  • Stomach sleepers likewise will be pulled down by their stomach and pelvic area into a soft mattress, while their neck stays higher up on the surface.

No matter what position you sleep in, a too-soft mattress will compress and tense the joints and muscles in the back and body, creating strain and worsening chronic pain.

Regardless of the studies, ultimately the ideal firmness for your clients is one that keeps their spines aligned, while providing comfort and support so they can stay asleep and allow their body to recover. Sleepers of heavier body weight will need a slightly firmer mattress in order to be properly supported. Beds that are labeled “plush” are likely too soft while memory foam beds labeled “ultra” or “extra” firm may be too firm.

Comfort and pressure point relief

Comfort of course is subjective, but some mattresses provide better pressure point relief than others, notably memory foam and latex beds.

These types of beds are both designed to distribute the body weight of the sleepers equally, contouring and conforming to pressure points. Memory foam provides the most pressure point relief of all mattress types, but it also tends to trap body heat and envelope the body in a way some may find overbearing. Latex beds offer a good alternative for sleepers who want a bit less contour and a cooler sleeping surface.

Individuals with chronic pain may benefit from a mattress topper. These provide a way to make a firmer mattress feel more cushiony. The right bed may provide proper support but feel too firm for the sleeper – a topper can easily fix this problem. There are even cooling mattress toppers available for those who tend to sleep hot.

Other considerations when mattress shopping

Encourage your clients to choose a mattress with free returns and a generous trial period of 30 days or more. It usually takes at least 30 days to get used to a mattress. The way you feel on a mattress after a full month of sleeping on it night after night is the true way to judge a bed, not the 15 minutes you spent lying on it at the showroom.

Up to a point, cost can be an indicator of quality. Once you get into the luxury arena, it doesn’t make a sizable difference, but a good quality mattress should cost around $1,000, give or take depending on features and mattress type (innersprings are often cheaper while latex and hybrid beds are more expensive). A new bed will reliably provide better support than an older one, but one study did find that cheaper beds correlated with more lower back pain than beds with mid- to high-price points.

What type of mattress is best for back, hip, or neck pain?

A 2015 review of multiple studies found that medium firm mattresses are ideal for improving sleep quality and reducing pain in patients. Memory foam and latex mattress provide the best pressure point relief, but air beds provide another mattress option for chronic pain sufferers, since their customizable firmness can be adjusted to ensure exact spinal alignment by individual.

  • Back Pain: Medium firm memory foam, hybrid, and latex mattresses can provide relief for back pain sufferers. Stomach sleepers should choose innerspring beds instead, to avoid sinking too deeply into the mattress.
  • Hip Pain: People with wider hips may require more give from their bed, so a softer mattress will help those areas sink more deeply. Memory foam and latex beds offer people with hip pain the most give for their hips. Whether they sleep on their side or their back, their hips can sink more deeply while the rest of the body is comfortably cradled.
  • Neck Pain: Medium firm mattress made of memory foam or latex will offer neck pain sufferers relief. Neck pain is often a result of the wrong pillow/mattress combination, which we’ll get into in the next section.

Pillow Considerations

Like their mattress, your client’s pillow needs to be just right to avoid exacerbating their pain.

Whether they sleep on their back, side, or stomach, a pillow with the proper height keeps the spine aligned with the neck and head. A pillow with too high a loft will tilt back sleeper’s chins down into their chest, side sleeper’s heads to the side, or stomach sleeper’s heads backwards and up. Get a pillow that is too low, and the weight of a back sleeper’s head will tilt their head backwards so their neck is unnaturally arched. For side sleepers, their head will tile the other way. As we mentioned above, no pillow is too low for stomach sleepers, as sleeping without a pillow is best.

Measure the proper pillow loft by having your patient lie down on their mattress and pillow as if they were going to sleep. Take a look at the curve of their neck and spine to see if it is still aligned. If not, you need to adjust the height. For side sleepers, measure the length from the nape to the end of the shoulders to find the right height. Our pillow guide explains how to properly measure pillow loft and find the best pillow for your sleep position.

The same 2015 review referenced above found that latex pillows and cooling pillows are best for chronic pain management, since they enhance sleep by stabilizing the cervical spine. Here are additional recommendations on pillow placement and the best types of pillows for chronic pain management:

Back sleepers can place a small pillow under the knees and even a flat one under their lower back. For their head pillow, a low to medium loft and medium firmness is best. They can also roll a small towel or use a roll pillow under the neck for additional support.

Side sleepers need the tallest pillows. A firmer pillow usually around 4 inches high will keep the head up and aligned. A pillow between the knees relieves pressure on the hips and back, while one between the ankles maintains alignment all the way to the feet.

Firmer memory foam or latex pillows are recommended, or a shredded memory foam pillow if less firmness is needed. A body pillow can also give throbbing or aching joints something else to rest on besides themselves.

Stomach sleepers should use no pillow at all or a very thin one for their forehead, made of down or feather. They can also put a flat pillow beneath their lower stomach to prevent sinkage.

Additional Resources

Online resources for patients

  • CyberPT is an online patient portal that helps individuals learn more about their own physical therapy needs, find providers near them, and connect with others via forums.
  • The American Chronic Pain Association provides educational resources on various chronic pain conditions, online support groups, pain management tools, and information on clinical trials.
  • There are many online support groups for chronic pain available on Psych Central, DailyStrength, Spine-Health, and Reddit.

Online resources for physical therapists

Video resources

  • Spine-Health offers a video library of strengthening exercises, stretches, and more for those with back pain and other chronic pain. One of their videos also explains how to find the best pillow for neck or back pain.
  • HASfit is a YouTube channel by two personal trainers who post a variety of 10 to 30 minute videos on exercises that provide relief for lower back, neck pain, shoulder pain.
  • The Sleepy Santosha YouTube channel offers several full-length yoga classes for chronic pain and fatigue, stiff joints, or fibromyalgia.

Additional BMR reading

  • In our article “Can Massage Help You Sleep Better?”, we review how massage helps patients with chronic pain, such as fibromyalgia, get better sleep. It includes a variety of massages your clients can perform themselves on their head, face, and feet.
  • Besides the mattress and pillow, there are many more assistive bedding products and devices that can help your clients enjoy better sleep. Learn about them in our Mattress and Bedding Guide for People with Disabilities.
  • If, after getting the right pillow and mattress, your clients are still experiencing unrestful sleep, it’s possible they have an underlying sleep disorder. From insomnia to hypersomnias, our Expert Guide to Sleep Disorders provides an overview of the most common sleep issues.

by: Sarah Winfrey