Pillow height and Neck Pain

It may seem surprising, but pillow height, the type of pillow and how we sleep can contribute to some forms of shoulder, back and neck pain. After all, we spend significant amounts of time each day lying in bed. Soft tissues and structures within the body can experience sustained loading if inadequately supported. Soft tissues include ligaments, tendons, muscles, bursae fascia and parts of joint structures. Changes to such tissues can impact joint mechanics, stability, tensional forces and result in pain. Hence, correct pillow height can help relieve neck pain and even help prevent it. Waking up with neck pain or a sore neck in the night or morning may indicate issues with sleeping position or head support. However, in some cases, other irritant factors arising during the day may only appear during the night or overnight, such as neck pain. Effectively, loading refers to forces that stretch or compress tissues and underlying structures. The article on Biotensegrity covers loading in far more detail. Our sleeping position can directly impact our bodies' loads while sleeping. Yet other factors, like pillow height and sleeping surfaces, such as our bed, also have relevance.

Tissues can respond to excessive short-term or prolonged overloading in slightly different ways. Responses may include tension, pain, and restricted mobility. Painful muscle spasms are another common symptom. Myofascial trigger points can also form due to overloading or injury, producing local or referred pain. Myofascial Trigger Point treatment aims release these areas of tension and pain with myofascial release techniques. A pillow that effectively cradles the neck can help relieve neck pain. The body naturally tries to find positions of comfort when in pain, which is good short term. However, tissues can then adapt to such positions of comfort, causing further problems later. Such a situation can then gradually lead to chronic neck pain.

Belly sleeping in a prone position involves having the neck twisted to one side for extended periods. This position does not properly cradle the neck and can result in tissue adaptations, leading to neck pain. Equally, some people may sleep with their arm above their head, lay directly on the arm or place their hand/arm underneath the pillow. In many cases, such sleeping positions have become long-term habits. However, there are helpful ways to change such habits.

In some cases, such as Thoracic Outlet Syndrome (TOS), people may sleep with their arm extended above their head or underneath their pillow, as this position helps relieve symptoms. However, this does not address the cause of the problem and can easily result in chronic neck pain and worse TOS symptoms. Initially, having the arm under the pillow can reduce the tension on the tissues, which causes the TOS symptoms. However, the tissues then adapt to a shortened state of having the arm above the head or under the pillow while sleeping. Issues are likely noticeable during the day and when the shortened tissues press on other structures, producing classic TOS symptoms.

Sleeping on the back tends not to cradle the neck properly, contributing to neck problems. Equally, back sleeping can result in disturbed sleep due to the effect of gravity on a relaxed tongue and the potential for airway obstruction. Incidentally, research has shown links between both forms of sleep apnea, obstructive sleep apnea (OBA) and central sleep apnea (CSA), and back sleeping. Some medical conditions may result in little choice in sleeping position due to position of comfort or other factors.

Pillows and pillow height can directly impact head and neck position and the loads on soft tissues and other structures. Ideally, one wants to keep the head in a neutral position while sleeping, and pillow selection can make a huge difference. Sleeping on your side allows one to easily keep the head and neck in a neutral position. Pillows differ in size, shape, and material, including feathers, latex, memory foam, or foam. Also, the pillow will compress with the head's weight, with the average adult head weighing similar to a 10 lb bowling ball. Memory foam pillows and those made of latex tend to be firmer, so they compress less with the head weight. The correct pillow selection must consider the head's weight in cradling the neck in a neutral position. A pillow that is too high or too low causes increased tissue and structural loading. This loading typically affects the neck, shoulders, and upper back, leading to back, neck, and shoulder pain. Equally, adaptative tissue changes associated with shoulder and neck pain can contribute to other issues, including headaches and migraines. Hence, avoid pillows that are too high or soft and cannot cradle the neck and head in a neutral position.

It may seem surprising, but beds or sleeping surfaces are relevant to achieving the correct pillow height. Beds come in various types and firmness levels, and the bed's firmness directly impacts the correct pillow height. Hence, the proper pillow height to maintain a neutral neck and head position may vary between beds. A softer bed may require a reduced pillow height due to the body's weight sinking deeper into the mattress. A firmer bed may require an increased pillow height because the body barely sinks. Much like pillows, bed prices and types can vary hugely, though we spend a relatively high proportion of our lives in them, which is worth considering. Beds past their effective service life can create neck and back problems due to inadequate support. Most people will have experienced sleeping on a friend's sofa after an evening out, camping or extended travel at some point, resulting in an aching back and neck. Often, such situations involve a mix of incorrect pillow height and sleeping surface issues, resulting in tissue irritation and pain. Usually, such soft tissue irritation and associated neck pain resolve relatively quickly within days, provided no further irritation occurs.

The following two examples highlight how bed mattress and pillow selection can increase lateral neck flexion (curvature).

Example of inadequate neck and head support (low pillow)

The above example demonstrates how a soft mattress and insufficiently supportive pillow mix can add additional load to tissues and structures. Such a position results in additional compressive forces on tissue structures within the upper left portion of the shoulder, back, and neck. Equally, such a sleeping position also increases tensional forces to the upper right section of the back, neck, and shoulder. Sleeping without a pillow will likely result in similar issues, even with or without neck pain.

Example of excessive neck and head support (high pillow)

An excessively high pillow creates tensional forces similar to an insufficiently high pillow, though in reverse. Effectively, the left upper quadrant of the body experiences increased tensional forces, and the right upper quadrant experiences increased compressive forces.

It is relatively easy to correctly support the weight of the head and neck when sleeping on your side and without any specially shaped pillow. Hence, there are many suitable pillows for side sleepers. However, sleeping on the back creates additional and different support needs for the head and neck. The neck's arched shape effectively needs increased pillow support, yet the head does not. A contoured pillow (S-Shaped) is designed in an attempt to resolve the differing head and neck support needs. However, most such pillows come in a standard size, and we are all different.

Although many professionals within the MSK therapy field sell expensive pillows within a clinical setting, the good news is one does not have to buy a costly pillow. The author prefers firm pillows that maintain their shape, such as memory foam or latex pillows. Pillows also tend to come in set heights, so getting a slightly too-low rather than too-high is better. It is then easy to customise pillow height with a folded towel. The towel is placed underneath the pillow, either on the bed or in the pillowcase, to create the perfect height. Having the towel in a pillowcase also helps preserve the towel's folded shape. The following example uses a firm mattress and includes a folded towel underneath the pillow to achieve a neutrally supported head position.

A neutrally maintained head and neck position.

Like neck pain, sleeping can also aggravate or contribute to back pain. For example, lower back pain is common during pregnancy due to increased ligament laxity and weight carriage changes, as covered in the Biotensegrity article mentioned earlier. The position of our legs while sleeping can change loads placed on the lower back and may even contribute to some lower back issues. However, some simple changes in sleeping position can reduce loads on the lower back and help relieve back pain, especially in acute back pain cases. Although the fascial system connects everything within the human body, there are also specific links between the legs and back. Sleeping with a leg across the body while side-sleeping increases load to the lower back via the hip and leg. Such a position increases the Q-angle and forces it on the leg, hip, and back. Sleeping with the knees together would reduce the Q-angle and forces, and sleeping with a pillow between the knees would reduce it further.

Increased back load, leg across body.

Side-sleeping with the knees together does reduce some of the loads applied to the lower back via the hip and leg. Hence, the hip position is slightly more neutral than with the leg across the body.

Reduced back load, knees together

Side-sleeping with a pillow between the knees can often relieve pain, and similar is true for other lower back pain conditions. A pillow between the knees reduces the forces applied to the lower back via the hip and leg, creating a neutral hip position. On the other hand, sleeping with no pillow and the legs across the body increases such forces. Although many people may notice no benefit of sleeping with a pillow between the knees, it can make a big difference when dealing with many types of lower back pain . Some people also like to place a towel or small pillow between the ankles to reduce tension on the knee.

Neutral back loading via leg and hip