Thursday Thoughts: Explaining Back and Neck Pain in Bed | Modern Manual Therapy Blog

Thursday Thoughts: Explaining Back and Neck Pain in Bed

Patients in pain often have difficulty sustaining prolonged positions, especially at night. A reader recently asked me how I explain this to patients.

Points I often make to patients
  • your brain normally filters out more input than you perceive
  • having pain at night or certain lying positions is your brain being protective over the area that is bothering you
  • rarely this is a mechanical sensitivity but it seems so as we can change this threat perception and thus make the pain "go away" by moving around or changing position
  • example of left cervical and radiating arm pain
    • normally the patient favors sleeping on the left side
    • however, since the onset of pain, they are only able to lie on the left side for 1-2 hours before pain increases, forcing them to sleep in a less comfortable position
    • I explain to the patient that under normal conditions, when the brain is not being vigilant, the sensation of your bed and pillow are normally filtered out
    • upon first lying down, you feel them, then that sensation is lost, much like putting your clothes on
    • however, since there is an active "alert" for the area that is painful, the continuous sensation of the pillow and bed are meeting the pain thresholds, which are set lower due to the alarm going off in the brain
    • thus the preferred lying position now becomes threatening
    • lying in this position is no more damaging to any tissues than it previously was
    • once we reset the nervous system with education, movement, and manual therapies, these pain and movement thresholds raise, and you will be able to sleep on your preferred side
  • in effect, your goal for Pain Science Education is to treat this functional loss as a type of Allodynia, or a painful response to a normally non-noxious stimulus
  • we know that patients who are unable to lie prone, supine, sidelying, often rapidly regain this ability after their pain and movement thresholds are raised from our active treatments
  • encourage them to avoid testing this position too much until their ADLs are at least 50-75% improved
  • the more you avoid setting off the alarm, the less vigilant the CNS will be
  • it's a balance, they can try lying in their preferred position as they start to feel better, and they can work there way to lying for longer periods

Keeping it Eclectic...


  1. Hi Erson!
    Nice post and very good points on how to explain this phenomena to the patient using pain ed. One thing that I started thinking about is the 2nd and 3rd bullets from the bottom; Where do you draw the line of what is useful and helpful avoiding of the aggravating positions (or movements or activities) and when does it become harmful by promoting fear-avoidance behaviour?

  2. Hi Erson
    I enjoy your blog. I would agree with your points in regards to long standing pain complaints that are well beyonds typically healing times. However an acute or subacute patient that has sensitive tissues it would seem appropriate to teach neutral positioning and or avoidance of painful activities for a period of time. What are your criteria for deciding that patient has a sensitive nervous system versus an inflammatory/mechanical sensitivity?

  3. Simple, they have a directional preference or position of ease versus central sensitization typically has no relief to be found with either. Or at least not long standing or significant

  4. I keep the fear avoidance low by stating everything we are avoiding is temporary, and only until the alarm hasn't been tripped or no pain or functional limitations are seen within a 48-72 hour time frame. All interactions are positive and meant to give hope and dissuade fear. I'm very encouraging the entire time.