Considering Sleep.

I’m sure you get asked all the time by patients how they should sleep.

Here are some things that I have picked up to make my patients more comfortable, sleep better, and reduce their pain:

1) Don’t let patients sleep with the pillow(s) under their shoulders. Many patients sleep with pillows under their shoulders and their necks relatively unsupported. This can be especially true if there is a large amount of kyphosis in the thoracic spine leaving the neck in an extended posture.

2) Try supporting their arms. In sidelying use a “huggy” infront of their body so that they can rest their top arm. This can take some pressure off of the shoulder and decrease shoulder pain. In supine you can try putting smaller pillows under both arms. PT’s many times say this feels like they are floating and find it very comfortable. Many times either of these can be effective in preventing your patient from rolling over as well as helping them to sleep better. This is especially important in cases where rolling on their shoulders while asleep wakes them up due to pain.

3) They may need more pillows in sidelying.  In sidelying patient’s heads and necks will be higher than in supine so they may need to add a pillow or fold their current pillow over to support their neck in a neutral position.

4) Don’t forget the legs. Placing 1-2 pillows under the knees in supine and a pillow between the knees in sidelying can help to take pressure off of the back and help the patient to sleep. If it is not a back injury I usually leave this up to my patients, but most of them think it is more comfortable to sleep this way.

  In order for the patient to understand the importance of a proper sleeping position they first need to show you how they sleep, because their descriptions of how they sleep may be way different than how they actually sleep.  From here you can show them proper positions to sleep in and how their current sleeping positions may be contributing to their symptoms, especially for patients waking up with pain caused potentially by mechanical issues.  For neck pain you can support their neck and take the pillow out from your hands.  From here you can easily demonstrate an extended position where they are “reaching for the bed” (too few or too thin pillows) or a flexed position where they are “reaching away from the bed” (too many or too fat pillows).  When patients understand the mechanics of their body they can understand how “reaching for” or “reaching away” may be contributing to their symptoms.  I also inform them of the need to change their sleeping position.  If their sleeping position is causing them pain it is going to be much slower in therapy. If you explain this well, patients will understand that the 8 hours of stresses they are putting on themselves a night will be difficult to fight in the short time you have with them.

Only let your patients sleep on their stomach as a last resort or if special circumstances require this.  The problem with sleeping on their stomach is that they will have to rotate their neck to breathe putting pressure on facet joints for an extended period of time.  This is analogous to having a desk worker whose computer screen is directly over their shoulder.  We would correct a worker looking over his/her shoulder for 8 hours a day as soon as possible to help decrease their pain.  We should do the same to help decrease the stresses on a patient’s facet joint and help decrease their pain.  This is especially true if they are sleeping on a big pillow causing an extended and rotated cervical position.

I generally tell patients a firm bed is better than a super soft bed.  My thinking on this is that a super soft bed may allow them to sleep in awkward positions putting stress on muscles, ligaments, etc. As far as what type of pillow to use I usually tell them that they can use whatever is comfortable as long as it keeps them in a neutral position limiting the forces on their joints/ligaments.  If they are sleeping with additional pillows as you have suggested they may be hotter at night than they are used to and have to sleep with less covers.

One of the important things to consider other than limiting forces on injured tissues during sleep is the quality of a patient’s sleep.  Deep sleep is necessary  for growth hormone releases that will help with recovery from an injury.  If the patient is not getting quality sleep they will not be getting as much tissue recovery as they may need.  One thing you may have to balance is the quality of their sleep with the patient sleeping the way you want them to.  It may take some time for the patient to adjust to their new position.  Patients who continuously flop around will have to reposition their pillows every time.  After they get used to the positions they will be able to fall asleep quickly after repositioning. 

There are several other things that can be done to help your patients sleep better including exercise.  What are your suggestions?