What kind of pillow should I use?

The topic of what pillow to use for neck pain or posture comes up a lot in our clinic, and there’s never an easy answer that will apply to all people. The first answer is always, “it depends.” But that’s not very rewarding, so let’s go over some principles.

Principle #1: Keep your spine in a neutral position when you sleep. 

Whether you are a side-sleeper, or a back sleeper, you need to find a pillow that will allow you to keep your spine neutral. If you are a side sleeper, you will want to have a firmer and thicker pillow than if you sleep on your back. If you think about it, when you are on your side, your pillow will need to meet the space between your shoulder and your neck. It’s got to be thicker.

If you are on your back, you won’t need to have as much space between your head and the bed. Some people who are back sleepers even get away without any pillow at all. You’ll want to get yourself a nice, thin pillow if you are on your back. And, this pillow might even the kind that is super thin, but has a little more support for your neck.

To keep your spine neutral, you don’t necessarily need to know the way the curves in your spine are structured. You won’t need to know about the cervical lordosis and the thoracic kyphosis, for example. You just need to find a way to avoid side bending in your neck or low back, and avoid rotation in your neck or low back. When you’re on your back, your ears should be on the same plane as your shoulders and your hips. If I were to draw a line between these points, the line should be straight. In other words, you should avoid the trap of having your head propped up to high on a thick pillow. Back sleepers need to have a firm enough support in the rest of the back to avoid a dip between your shoulders and hips.

If you’re a back sleeper, the exception to keeping your neck horizontal, of course, is if you have sleep apnea. If you have sleep apnea and you sleep on your back, then your throat will tend to close down on your airway and restrict breathing. Sleep apnea is a special case where you might want to even prop up your upper back with a special wedge that will elevate your whole upper body, while still taking care to keep your spine neutral.

If you’re a side sleeper, it’s common to not have enough support for your head and neck. When on your side, you don’t sleep on the very point of your shoulder–that would be uncomfortable. Rather, you tend to sleep with your arm forward on top of the flat part of your shoulder blade. This can interfere to some degree with your resting shoulder position, and it’s why side sleeping is not as good as back sleeping. But if you do sleep like this, you need to visualize the distance between your shoulder and your neck. Too little support, and tour head will rotate and bend to one side, creating neck problems. Too much support, and your neck is elevated too much. Sleeping like this often causes an acute kink in your neck that be painful for a week.

Side sleepers often do well with a shredded memory foam pillow, which combines the thickness of memory foam with the soft breathability of a pillow with a looser type of material. The Chiroflow water pillow also tends to be a good choice for side sleepers, as you can change the thickness of the pillow by adding or draining water from the water pouch.

Principle #2: Don’t sleep on your stomach.

So what do you do if you have the bad habit of sleeping on your stomach? If you sleep on your stomach, you need to stop. There is no way to go face down and keep your spine neutral if you still want to breathe. Even if you borrowed a face cradle from your massage therapist, you won’t be able to comfortably sleep with the pressure on your face. Stomach sleepers turn their head at night to breathe. You have to breathe. And, having your head turned all night long is even worse than having a head-forward posture. It’s horrible. Having your head turned to one side affects the length and tone of the neck muscles. It’s positioning the joints in the neck in a way that sends a continuous neurological signal to your brainstem and cerebellum for postural processing, and the garbage-in-garbage-out signal processing is creating hard wiring that will hove profound effects on your balance, posture, and athletic abilities.

If you are a stomach sleeper, you will come to our clinic with tightness in your upper neck and an unconscious postural head-turn. When I check your neck, I will feel the spinous process of your C2 bone rotated all the way to one side. this will affect the tightness throughout your neck and probably your whole spine. This will give you a much higher likelihood of developing headaches. Tightness in your upper cervical complex of muscles will affect the neurological circuits going into your brainstem, and it will directly compress the nerves at the back of your head called the greater occipital nerve, and can cause pain from nerve compression. You can’t just get this adjusted back to normal very easily, either. Your chiropractor can’t work against 8 hours of sleep every night for 7 days a week with only a 5 minute weekly adjustment.

Don’t sleep on your stomach.

Principle #3: Allow yourself time to get use to your new pillow. 

If you’re having neck pain and you want to be proactive about every aspect of your life, and you are getting what you think will be the best pillow, you might be disappointed at first. You need to allow yourself to adapt to your pillow for a few weeks before you make a judgement about how it is working for you. Even when you first lay yourself down to sleep, you need to allow yourself 10-15 minutes for your neck muscles to fully adapt and relax into your pillow. For this reason, you can’t really tell what kind of pillow is best for you with a brief squeeze at the store. But, when you do get a new pillow, allow yourself to get use to it for a few weeks.

Also realize that when you make a change to your pillow, but change nothing else about your lifestyle, you might be feeling the effects of your work ergonomics or your recent neck pain episode, but since your new pillow isn’t bringing you relief, then it’s easy to say that it isn’t working for you. During the day, you are active. You are moving around, and your movement receptors in your muscles and joints are bringing signals to your spinal cord and brain even when you are merely sitting. Your movement throughout the day triggers pain-relieving signals in your spinal cord and brainstem, and this makes it so you don’t feel the pain as much as you do when you wind down for the day. When you are laying in bed, you might feel the throbbing from an injury, or the ache from tight muscles more. And even if your pillow is supporting you properly, you can still feel the effects of your waking hours.

Principle #4: You pillow surface should be soft.

As you use your pillow, and you are counting on a good night’s sleep, you will want to minimize the pressure points on your skin. Some pillows are just too hard on the surface, and this surface hardness will blanch your skin. It will put pressure on your skin, and it will starve your skin of the blood flow. The capillaries will be compressed. This is usually not harmful for the long term, but it will be uncomfortable. If you were to measure out the pressure levels on certain parts of your head, neck, and face while you are lying on your pillow, you don’t want any pressure points, because these pressure points over time will turn achy on you. You want the weight of your head to be evenly distributed. This is particularly important if you are a side-sleeper. If you are on your side, and your pillow is pressing against your cheek, and starving your cheek skin of blood flow, you are causing wrinkles and impairing your ability to recover from sun damage and facial muscle tension from your day. You are going to want to allow some recovery.

In our office, we carry the Chiroflow pillow. This is a pillow that has a water pouch built into it, and you can adjust the amount of water to your level of comfort. With the water pouch, under the layer of soft fill, the water will shift out of the way when you reposition yourself on it. The dynamic way that the pillow changes shape has been shown to reduce the forces translated to your head, neck, and face when you are sleeping.

Principle #5: Reduce the pressure on your shoulders and hips.

When you are lying on your side, common pressure points include your shoulder and your hips. If you are feeling hip pain, and perhaps developing a bursitis type of pain on the side of your hip, you are either going to want to train yourself to be a back sleeper, or you will want to get a softer surface for your mattress. This mattress topper can be memory foam, soft synthetic fill, or cotton. It can be 1″ to 4″ in depth, and it will all depend on your budget. If you are currently battling a pain in your hip, then you might want to go softer and deeper from a strictly orthopedic perspective. It might be worth it to get a topper that is a little softer than you otherwise would need to help you take care of the problem.

You’ll also want to experiment with other supporting pillows for your body to minimize pressure points on your shoulders and hips. While sleeping on your side, a pillow between your knees will help keep your knees in line with the hip joints in your pelvis. If you are able to avoid too much angle between your hips and your knees, this will help you avoid a tendinopathy that you can develop across your hip joints because the tendon is stretched at an unnatural angle. Some runners will blame their tight TFL (tensor fascia lata) and IT (iliotibial) band on their running, but it can also be affected by their sleeping posture. The IT band runs from your hip bone on your side, down your thigh to your knee, and it provides added stability to your hips, thighs, and knees. It’s common to have a tightness develop in your IT band, and therapists often try to fix it by stripping the muscles and fascia. In effect they are beating it all up, but they are not addressing postural issues that are a more direct cause of the pain.

Published by Todd Lloyd

Dr. Lloyd is a chiropractor in San Francisco. He maintains an active interest in treating neck and shoulder pain and dysfunction.

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