You’ve had a long day and your back is hurting. All you want is a good night’s sleep. But you can’t seem to fall asleep or stay asleep because your back hurts. Experts call this the pain-sleep cycle. It’s when back pain interferes with sleep, and when poor sleep worsens back pain. The good news: It doesn’t matter whether the chicken (pain) or the egg (poor sleep) came first — there are ways you can break the cycle to simultaneously reduce back pain and improve sleep quality.  

Here, learn more about how to sleep better when you have low back pain — especially with exercises from our Hinge Health physical therapists.

The Pain-Sleep Cycle

About one in three adults report that they don’t get the sleep they need to feel their best. That number is even higher for people with any type of musculoskeletal pain. A 2021 study published in the European Journal of Pain found that people with chronic low back pain are 58% more likely to report sleep problems than those who get enough zzz’s. 

“Sleep is important for back pain because your body needs to repair itself,” explains Heather Broach, PT, DPT, a physical therapist at Hinge Health. “But if you’re in pain, you’re less likely to get the sleep you need.“ And poor sleep can be a major factor in your pain backpack. The pain backpack is an analogy Hinge Health physical therapists use a lot. 

Imagine every factor that contributes to your pain (e.g., a previous injury, poor sleep, stress) goes in a backpack. Everyone carries unique factors in their backpacks, some of which may contribute to your pain more so than others. But when your backpack becomes so full that you can’t zip it shut, your body sends a warning in the form of pain. Fortunately, there’s always something you can do about this. You can address the pain contributors that are within your control with approaches that include movement, education, social support, and other lifestyle modifications.

Word from Hinge Health

When you can't sleep well because of your back pain, things can feel frustrating, upsetting, or even a little hopeless. Good sleep is so essential for daytime energy, a strong immune system, a healthy metabolism, and so much more. No matter how rough your sleep or back pain may be, know that you can always do something to help improve it. And the silver lining about the pain-sleep cycle is that small tweaks to either your sleep routine or to your back pain management can positively affect the other. Sleep may be a big factor in your pain backpack, but you're in the right place to get support for dealing with it.

Best Sleeping Positions for Low Back Pain

Simple tweaks in your sleeping position can take a lot of strain off your back. Any of these positions are good options to try: 

• Reclined. A reclined position means you’re on your back but your upper chest is propped up at a 45-degree angle to give your back and trunk additional support. You can use pillows to prop yourself up when lying in bed, or you can sit in a recliner chair when doing things like watching TV. 

• On your side with a pillow between your knees. This helps keep your hips, pelvis, and spine in alignment to help reduce pain and keep you comfortable when you sleep. Make sure you use a good, firm pillow between your knees — not a wimpy one. 

• Fetal position. This means your knees are tucked in toward your chest, and your torso is curled in toward your knees. “It’s a very primal, instinctual position that relaxes your whole body, including your low back,” explains Dr. Broach.

• Flat on your back. For optimal spine alignment, place one pillow underneath your head or neck and another underneath the backs of your knees. This causes your pelvis to shift toward the bed, which relaxes the surrounding muscles and helps your spine shift out of an extended position. 

Sleeping on Your Back? Really? 

If you sprain your ankle you want to temporarily put less load on that leg to prevent pain and let the injury heal. So if your back hurts, you probably want to put less load on it, including when you sleep, right? 

Actually, no. Research shows that sleeping on your back may be the best position for low back pain and sciatica because it can help keep your spine aligned. This helps relieve pressure on your back and spine. 

What if sleeping on your back isn’t comfortable? In fact, what if none of the positions above are comfortable for you? It might take some trial and error, but there’s a solution. It might just require thinking outside the box, says Dylan Peterson, PT, DPT, a physical therapist at Hinge Health. Start by finding which position is most comfortable for you, then add in additional steps, like sleeping on a different mattress, taking a warm bath before bed, or getting up to walk around your home if pain wakes you up in the middle of the night. 

What About Stomach Sleeping? 

Sleeping on your stomach tends to not be the best position for people with back pain. Since it flattens the natural curve of your spine, it puts more pressure on your spine’s muscles and joints. It also makes you turn your neck, which may cause neck and upper back pain. However, if sleeping on your stomach is the best way for you to fall asleep, then it’s the best position for you. 

If you prefer sleeping on your stomach, Dr. Broach recommends putting a small, flat pillow under your hips and ribs to elevate your mid and low back and keep your spine in a neutral position. 

Sleep Hygiene with Back Pain

In addition to finding a sleep position that works for you, take a look at your sleep habits. Small improvements to your sleep routine can help you sleep better and reduce back pain, which helps break the pain-sleep cycle. The following tips can help you fall asleep and stay asleep (no more tossing and turning or 4 a.m. clock watching, thanks), and also reduce back pain when sleeping: 

Find a good pillow. You want one that will help you achieve a neutral spine. If you’re a stomach sleeper, that usually means a thin one to keep your neck in alignment. If you’re a back or side sleeper, you can use a thicker pillow, as long as your spine remains neutral. If you’re not sure what that means, think about keeping the bridge of your nose or the midline of your face parallel to the ground. Just know that you don’t need to spend extra money on therapeutic pillows. Dr. Broach says standard or cheaper options work just as well. 

Invest in a good mattress. A medium-firm one is best, according to a 2021 study published in the Journal of Orthopedics and Traumatology. Not sure if you need a firmer one than what you’re currently using? Put a plywood board under your mattress, or place your mattress on the floor. If you notice an improvement in pain or comfort, it’s probably worthwhile to shop for something firmer.

Rethink your bedtime routine. Be intentional about what you do before bedtime and be consistent with your evening routine. It’s best to get up at the same time each morning so you feel tired around the same time each evening. Set a timer one hour before bed as a reminder to start winding down. During this time, you can:

• Dim the lights. Bright lights are stimulating and can decrease levels of the hormone melatonin, which helps you sleep.

• Turn off electronic devices. Or place them in another room or out of reach. The blue light from screens can make it harder for you to fall and stay asleep. Instead, read, journal, make a to-do list for tomorrow, reflect, color, or do anything else that soothes you. 

• Drink herbal tea, such as chamomile or lavender.

• Take a warm bath. In addition to helping you relax, soaking in a warm bath can increase circulation and reduce pain.

• Do some gentle exercises. Targeted movements, exercises, and stretches increase the strength and flexibility of the structures in and around your back. (More information on this below.)

Keep your room quiet and dark. Experts suggest keeping the temperature of your room around 65 degrees Fahrenheit. You can use a white noise machine or blackout shades to help.

Exercise during the day. Just 30 minutes of moderate exercise can increase your quality of sleep (though it’s best to avoid strenuous activity within two hours of bedtime as this can actually disrupt sleep for some people). Take breaks throughout the day for walking, stretching, or anything else that gets you moving. If you can get your exercise outside it’s even better. Exposure to natural sunlight (or bright light) during the day helps keep your circadian rhythm — or sleep cycle — on track. 

Practice relaxation techniques. These can help distract you from your back pain and help you fall asleep. One good technique to try is called diaphragmatic breathing, or belly breathing. A 2017 study published in the Journal of Sports Rehabilitation found that this type of exercise helped to reduce back pain. Here’s how to do it: 

• Sit in a comfortable chair, with both feet on the floor. 

• Breathe in slowly through your nose using only your diaphragm (your belly should swell out as you breathe in).

• Exhale slowly through your mouth (your belly should fall back in as you breathe out). 

• Count each time you breathe in, going up to 10 breaths then back to one (for a total of 20 breaths). 

You can explore other relaxation techniques to see what works for you, such as guided meditation or listening to calming music or a podcast before bedtime. 

When to See a Doctor

Most cases of back pain get better within a few weeks without treatment. But you should see your doctor if your back pain:  

• Is constant or intense when you lie down 

• Spreads down one or both legs

• Causes weakness, numbness, or tingling in one or both legs 

• Is accompanied by weight loss

• Occurs with swelling or redness

• Is associated with any changes in bowel or bladder function

While changing your sleep position and habits can help you get some much-needed rest, one of the most effective ways to manage back pain and improve sleep is exercise therapy. These gentle exercises from Hinge Health are great for stretching your back. You can do them throughout the day when you’re experiencing a pain flare or before bed to calm down your pain system.

The information contained in these videos is intended to be used for educational purposes only and does not constitute medical advice or treatment for any specific condition. Hinge Health is not your healthcare provider and is not responsible for any injury sustained or exacerbated by your use of or participation in these exercises. Please consult with your healthcare provider with any questions you may have about your medical condition or treatment.

PT Tip: Sleep in a Simple Position

“People often get into very contorted positions when they sleep,” says Dr. Broach. “Instead, try to settle into a position that mimics floating in water.” When you float in water, the ligaments, joint capsules, tendons, and muscles surrounding your limbs don’t have to work very hard. If you can mimic this position when sleeping, it may help reduce pain. 

“I use this image to help highlight odd positions someone may be sleeping in, like with your arms overhead, your legs pulled up, an arm tightly wound around a pillow, or your wrists tucked under your chin,” says Dr. Broach. “All of these are sustained positions that may contribute to pain. Many issues can be resolved by just creating an awareness of these positions.” 

One way to help ensure you fall asleep and stay asleep is to strategically place pillows under your knees if you’re a back sleeper, or between your knees if you’re a side sleeper. When you turn, don’t twist or bend at your waist as this can worsen back pain. Rather, keep your belly pulled in and tight, and bend your knees toward your chest.

How Hinge Health Can Help You

If you have joint or muscle pain that makes it hard to move, you can get the relief you’ve been looking for with Hinge Health’s online exercise therapy program.

The best part: You don’t have to leave your home because our program is digital. That means you can easily get the care you need through our app, when and where it works for you.

Through our program, you’ll have access to therapeutic exercises and stretches for your condition. Additionally, you’ll have a personal care team to guide, support, and tailor our program to you.

See if you qualify for Hinge Health and confirm free coverage through your employer or benefit plan here.

This article and its contents are provided for educational and informational purposes only and do not constitute medical advice or professional services specific to you or your medical condition.

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