Sleep, Pain and Recovery

Sleep, Pain and Recovery

Physiotherapy for sleep-related musculoskeletal problems, including when pain, stiffness or poor sleep are affecting recovery

Sleep and physical health are closely connected.

Pain can make it difficult to fall asleep, stay asleep or find a comfortable position. In turn, disrupted or insufficient sleep can contribute to greater pain sensitivity, fatigue, stiffness, reduced concentration and difficulty tolerating exercise, work and everyday activities.

Sometimes the issue is relatively simple, such as neck pain from an uncomfortable pillow or difficulty finding a suitable sleeping position. In other cases, poor sleep may form part of a broader persistent pain or recovery problem.

Sleep is considered as part of the overall physiotherapy picture when it is relevant to pain, movement, physical function or recovery.

Sleep and musculoskeletal pain

Sleep and pain can influence each other in both directions.

Pain may interrupt sleep because of:

• Difficulty finding a comfortable position

• Pain when rolling or changing position

• Shoulder or hip pain when side sleeping

• Neck or back stiffness

• Muscle tension

• Repeated pain flare-ups overnight

• Worry about aggravating an injury while sleeping

Poor sleep may then contribute to:

• Greater pain sensitivity

• Increased fatigue

• Reduced exercise tolerance

• Greater muscle soreness or stiffness

• Reduced concentration

• Difficulty managing work and daily activities

• Lower tolerance for physical and emotional stress

This does not mean that pain is caused by poor sleep alone.

Rather, sleep may be one of several factors influencing how the body and nervous system respond during recovery.

Is there a “best” sleeping position?

There is no single correct sleeping position for everybody.

The most important consideration is usually whether the position allows you to sleep comfortably and wake reasonably rested.

Different positions may suit different people.

For example:

• Side sleeping may be comfortable for many people and can sometimes reduce snoring compared with sleeping on the back

• Back sleeping may suit some spinal or shoulder presentations but can worsen snoring in some people

• Stomach sleeping is not automatically harmful, although prolonged neck rotation may aggravate some neck conditions

• Shoulder, hip or spinal pain may require temporary changes in positioning or additional pillow support

The goal is generally not to force yourself into a supposedly “perfect” sleeping posture.

Instead, physiotherapy can help identify whether your current position is contributing to symptoms and whether a practical modification may improve comfort.

Pillows and neck pain

There is no single pillow that is best for everyone.

A suitable pillow depends on factors such as:

• Your usual sleeping position

• Shoulder width and body size

• Mattress firmness

• Neck mobility

• Pillow material and how much it compresses

• Personal comfort

A pillow that works well for one person may be uncomfortable for another.

If the pillow positions the head too far forward, backward or sideways for many hours, the neck may become irritated or stiff.

Sometimes the solution is not to buy another expensive pillow. A small change in pillow height, positioning or additional support may be enough.

Expensive contour, memory foam or “orthopaedic” pillows are not automatically better. The important question is whether the pillow suits you.

Snoring and sleep position

Snoring is common and does not always mean that something is medically wrong.

However, sleeping position can influence snoring.

For many people, snoring is worse when lying on the back because the tongue and soft tissues of the airway are more likely to fall backwards.

This means that deliberately training yourself to sleep on your back may not always be helpful, even if a particular pillow or product has been marketed for snoring.

Side sleeping may be more suitable for some people.

Physiotherapy can assist with the musculoskeletal aspects of positioning and comfort, but it does not replace medical assessment for a suspected sleep disorder.

Further assessment by a GP or sleep physician may be appropriate if snoring is associated with:

• Waking choking or gasping

• Witnessed pauses in breathing

• Significant daytime sleepiness

• Persistent morning headaches

• Waking consistently unrefreshed

• Difficulty concentrating

• Other concerns regarding possible sleep apnoea

Restless legs and night-time leg discomfort

Restless-leg-type symptoms can significantly interfere with sleep.

People may describe:

• An uncomfortable urge to move the legs

• Difficulty keeping the legs still

• Symptoms that are worse when resting

• Symptoms that are more noticeable in the evening or at night

• Temporary relief with movement, stretching or walking

However, not every uncomfortable leg symptom is true Restless Legs Syndrome.

Muscular tightness, nerve irritation, vascular conditions and other medical factors may sometimes produce similar symptoms.

Physiotherapy may help assess whether there appears to be a musculoskeletal contributor and may trial simple strategies such as stretching, movement or activity modification.

Persistent or significant restless-leg-type symptoms should also be discussed with your GP, particularly if they are regularly disturbing sleep.

Sleep after illness, injury or inactivity

It is common to feel stiffer after spending several days in bed because of illness or injury.

Reduced activity, prolonged positioning, coughing, disturbed sleep and temporary changes in normal movement can all contribute to muscular discomfort.

This does not necessarily mean that something has been damaged.

As recovery progresses, gradually returning to normal movement, exercise and everyday activity is often helpful.

Physiotherapy can assist where pain, weakness or uncertainty makes this difficult.

Assessment may include discussion of:

• Your usual sleeping position

• Pillow and mattress setup

• How pain affects your sleep

• Whether symptoms wake you during the night

• Morning pain or stiffness

• Snoring or other sleep concerns

• Daytime fatigue

• Physical activity and exercise

• Recent illness or prolonged inactivity

• Stress, work demands or other factors affecting recovery

• Whether further assessment by your GP or a sleep physician may be appropriate

Experience in sleep and pain

Kevin completed his PhD at the University of Sydney investigating sleep and chronic musculoskeletal pain, including spinal pain and osteoarthritis.

This research informs his approach to the relationship between sleep, pain sensitivity, physical function and recovery.

Kevin is also undertaking the APA Pain Physiotherapy titling pathway, with further training in persistent pain and psychologically informed physiotherapy.

Where relevant, sleep is considered alongside movement, strength, physical activity, stress, confidence and other factors influencing recovery.

Treatment focus

Treatment depends on what appears to be contributing to your sleep-related problem.

This may include:

• Advice regarding sleeping position

• Pillow assessment and practical modification

• Neck, shoulder, spinal or hip mobility

• Strength and movement retraining

• Hands-on treatment where appropriate

• Strategies for night-time pain or stiffness

• Gradual return to activity after illness or prolonged inactivity

• Exercise planning around fatigue

• Education about the relationship between sleep and pain

• Strategies for persistent pain and flare-ups

• Referral back to your GP where a primary sleep disorder or medical issue may require further assessment

The goal is not to create a perfect sleep posture or prescribe one pillow for everyone.

The aim is to identify practical factors that may be interfering with comfortable sleep and recovery.

Sleep and persistent pain

Sleep can become particularly important when pain has persisted for months or years.

Persistent pain may be influenced by several interacting factors, including:

• Physical loading

• Sleep disruption

• Stress

• Illness

• Changes in activity

• Work demands

• Mood

• Pain-related worry

• Previous pain experiences

Considering sleep as part of persistent pain management does not mean that the pain is “psychological”.

Sleep is a biological process that can influence how sensitive the nervous system becomes and how well the body tolerates physical and emotional load.

If sleep difficulties are occurring alongside long-standing, sensitive or complex pain, see Complex Pain Physiotherapy for more information about the broader approach to persistent pain rehabilitation.

For some people, improving sleep and reducing night-time discomfort can make rehabilitation and everyday activity easier to tolerate.

What to expect

Your appointment may include:

• Discussion of your sleep and pain history

• Assessment of the painful area

• Review of your usual sleeping position

• Pillow assessment where relevant

• Movement, strength or mobility testing

• Hands-on treatment where appropriate

• Advice regarding positioning and sleep comfort

• Exercise or activity planning

• Identification of factors that may require GP or sleep specialist review

You are welcome to bring your pillow to the appointment if you would like it assessed.

Book an appointment

If pain, stiffness or your sleeping position is interfering with your sleep, Physiotherapist Dr Kevin Ho can help assess whether there are practical musculoskeletal factors that may be contributing.

If your sleep problem appears more consistent with a primary sleep disorder, medical assessment may also be recommended.