Sleep support for rehab patients is an important adjunct to the chiropractic treatment plan

Rehabilitation patients with chronic and/or acute neck pain often receive information from various marketing sources for special neck support pillows. Cervical support pillows are recommended by many doctors of chiropractic, physical therapists, and even surgeons. In the comparison study of three types of bed pillows, Ambrogio¹ writes, "From a patient’s perspective, neck support is an important part of a comprehensive physiotherapy program." Most bedding stores have at least one special pillow for people with neck pain.

Is there any scientific support for claims made for better sleep, decreased neck pain, and fewer headaches? When a patient has chronic neck problems or has received an injury to the neck, does it make sense to recommend a cervical support pillow as part of rehabilitative care? Which of the many different designs of support pillows is most likely to be helpful for patients? Are there any risks or problems associated with the use of cervical pillows?

While many chiropractors have used and recommended cervical support pillows for years, the scientific evidence for benefit has been weak, at best. Often, empirical and anecdotal reports from patients who communicate improved sleep and decreased pain are all that is available.

Don’t Lose Any Sleep
Three scientific studies^2-4 have attempted to address some of the questions regarding cervical pillows. Although each takes a different investigative approach and evaluates each individual pillow (findings are not directly comparable and no definitive conclusions can be made), the results are still worth consideration, since it provides some guidance in selecting a support pillow for our patients.

Two-pillow comparison study: This study,² performed at the Johns Hopkins University School of Medicine, Baltimore, recruited 46 subjects with chronic neck pain and cervicogenic headaches. The investigation compared daily pain levels, sleep quality, and medication consumption during 1 week on their own pillows, followed by 2 weeks on two special neck support pillows—cervical roll and water-based cervical styles. A statistically significant improvement in all scores was recorded when using the water pillow. Most subjects preferred the water pillow to their own pillow, and many had a difficult time sleeping on the roll pillow. In fact, researchers reported that some of the patients had to discontinue the 2-week trial of the roll pillow due to significant discomfort.

Investigators felt that the higher satisfaction ratings for the water pillow were due to its ability to conform better to the position and shape of the subjects’ head and neck during various sleep positions. They believe that the roll pillow was not well-tolerated due to its tendency to exaggerate the extension of the neck when supine, since there was no support underneath the head.

Single-style study: A small feasibility study³ at Canadian Memorial Chiropractic College found very different results. After recording 2 weeks of baseline pain ratings in 30 subjects with chronic neck pain, the researchers supplied a roll-type cervical pillow (a soft cylinder shape). Of those who continued to use the pillow for 4 weeks (many subjects found the pillow to be very uncomfortable initially), most reported decreased neck pain. However, three subjects described increased neck pain during use of the pillow, and two women dropped out of the trial, saying they were unable to tolerate the discomfort they experienced while using the cylindrical pillow. Since the data collected do not reflect these "pillow failures" and because there was no placebo or comparison with other pillows, the conclusions should be considered overly optimistic. This demonstrates the difficulty in designing a valid and pragmatic scientific investigation.

Six-pillow comparison study: At Lund University Hospital in Sweden, researchers4 studied the responses of 55 subjects for 3 nights on six different pillows. However, none of the six pillows were the subjects’ own pillows, and none was the same as the two types studied in the previous experiments. Since roll-type pillows were not included, we are left without a practical comparison to the other studies.

The subjects rated the six pillows for comfort and were also asked about pain reduction and sleep improvement. The six pillows varied in design, materials, and construction.

One pillow stood out from the rest as the most comfortable, and also the most likely to decrease chronic pain. Rated the best by both men and women, this pillow is made of soft polyurethane with two firm supports along the edges—one side is high, while the other is lower. This pillow has an easily-tolerated support for the neck, while the two different sides provided a choice of heights. The pillow rated the lowest was the one that most closely resembled a roll pillow.

The investigators concluded that the optimal neck pillow to reduce neck pain and improve night rest was a soft, not-too-high pillow with support for the cervical lordosis from a choice of firmer cores. Since participants used each pillow for only 3 nights, and only comfort ratings were evaluated, no conclusions can be drawn from this study regarding the long-term effect of these pillows on pain or sleep patterns.

A Good Night’s Rest
When chiropractic patients report chronic neck pain and/or cervicogenic headaches, or when a patient has been instructed to perform rehabilitative cervical exercises, a cervical support pillow should be considered. This is especially true when pain is described as being worse in the morning and improving during the day. If sleep disturbances are part of the history, or accompany a history of injury to the neck, a comfortable, yet supportive pillow should be a part of the chiropractic treatment recommendations.

The correct pillow will vary depending on the size of the person and the amount of neck support that can be tolerated. Roll-type cervical pillows are initially uncomfortable, and may worsen symptoms in some patients. A pillow that supplies a choice of sides is more likely to be helpful to a broader range of patients. It is also important to reevaluate patients’ pillows to ensure that proper cervical support continues over time.

Recommending the use of a good cervical support pillow and supplying one that has a good track record can be one of the most useful adjunctive procedures to rehabilitative treatment of neck pain. Patients appreciate the doctor who goes beyond the office setting to give advice regarding supportive home activities, and even specific sleep recommendations.

About the Author
Kim D. Christensen, DC, CCSP, DACRB, is codirector of the SportsMedicine & Rehab Clinics of Washington, and current president of the American Chiropractic Association Rehab Council. He can be reached at Chiropractic Rehabilitation Association, 18604 NW 64th Ave, Ridgefield, WA 98642 or via email: kimdchristensen@hotmail.com. 

References
1. Ambrogio N, Cuttiford J, Lineker S, Li L. A comparison of three types of neck support in fibromyalgia patients. Arthritis Care Res. 1998;11(5):405–410.
2. Lavin RA, Pappagallo M, Kuhlemeier KV. Cervical pain: a comparison of three pillows. Arch Phys Med Rehabil. 1997;78:193–198.
3. Hagino C, Boscariol J, Dover L, LeTendre R, Wicks M. Before/after study to determine the effectiveness of the align-right cylindrical cervical pillow in reducing chronic neck pain severity. J Manip Physiol Therap.1998;21(2):89–93.
4. Persson L, Moritz U. Neck support pillows: a comparative study. J Manip Physiol Therap. 1998;21(4):237-240.