Low back pain is a common issue that affects millions of people, often becoming most noticeable in the morning. In fact, back pain is the most common cause of disability worldwide! Some 80+% of people may experience back pain at some point in their lives. Fortunately, the overwhelming majority of episodes of back pain are not cause for medical concern. However, for those in the midst of an episode of lower back pain, morning back pain and stiffness is often the worse. Stiffness and discomfort upon waking can be caused by many factors such as sleeping position, muscle tension and or muscle injury, stress, or a sleeping surface or mattress that you are not accustomed to and/or suitable for your needs. Back muscles can become tense overnight, leading to pain that eases as movement increases. While frustrating, morning back pain is typically manageable, and with some simple tips and suggestions, back pain upon waking can be minimized and or resolved, allowing individuals to start their day fresh with greater energy and more mobility

Back pain in the morning. Why do you wake up with back pain?

The causes of lower back pain upon waking are many.  As always, it is recommended you speak with your trusted health providers, such as the expert physiotherapists at REP Physio in Edmonton to determine the cause of your back pain and an appropriate treatment plan.  What follows are some of the more common causes that can lead to morning back pain.

First and foremost, episodes of severe back pain without any method of injury, that also include changes to bowel and/or bladder function (incontinence) and/or back pain symptoms that are also accompanied by unplanned weight loss and/or severe bilateral leg pain should be seen to urgently. Although rare, this type of lower back pain may suggest potential nefarious lesions and/or too much pressure on the spinal cord (cauda equina syndrome).  This type of lower back pain should be seen to urgently, and is not the subject of this blog post.

Can your sleeping position be causing back pain that is worse in the morning?

Yes, your sleeping position may be causing you to experience lower back pain.  While there is no strong evidence that certain habitual sleeping positions are associated with more pain on waking, certain positions may place increased load and/or pressure on back, which may pre-dispose you to back (and neck!) pain upon waking.  What follows are some simple tips for typical sleeping positions

Back sleeping causing you to wake up with back pain

For back sleepers, morning lower back pain may be able to be minimized with the addition of one or two pillows placed under the thigh and or knee. Without support under your legs and/or thighs, your back back and pelvis may assume a slight anterior tilt outside of a neutral spinal alignment.  Overtime, this may cause increased pressure on your joints and muscles in your back, and may contribute to morning pain. Sleeping on your back with pillows under the legs helps support your back in ways that a mattress alone cannot.  Again, similar to side sleeping and stomach sleeping, the goal is to wake up in the morning with minimal pain by assuming a neutral position of the spine. S  By neutral spine position, we mean that all 3 curves of the spine (neck, thoracic and lumbar) are present, comfortable and “balanced”.  Some people may even choose to sleep with a bolster to take pressure off sensitive joints and muscles in the back if pain in the lower back is more severe.

Stomach sleeping causing morning back pain

Stomach sleeping may predispose your lower back to an increased chance of irritation.  Stomach sleeping can take your spine out of a “neutral” position and may increase load and/or pressure on the load bearing joints in your spine known as the facet joints. To relieve lower back pain due to stomach sleeping, we recommend that if you sleep on your stomach, you place a small pillow under your hips and lower  abdomen to reduce pressure allow your spine to assume a neutral resting position.

Side sleeping causing back pain in the morning

For side snoozers, we recommend placing a pillow between your knees to allow your back to assume a neutral alignment and reduce back pain. Without pillow support, your pelvis and hips have a tendency to rotate, which can cause some added stress on sensitive joints and muscles.  Ideally, your knees should be in line with your hips.  If you are a side sleeper that sleeps with the bottom leg straight and the other leg bent at the knee and hip (top leg), you may need one or more pillows (or a really tall pillow) to support the top leg. Again, find a position that is comfortable while allowing the top leg to rest easily in line with your hip. Side sleepers may also require a taller pillow so the neck is adequately supported with the spine in neutral alignment to allow you to wake up in the morning with minimal or no discomfort.

Other common causes of morning lower back pain

Osteoarthritis

Symptoms of osteoarthritis include moderate or mild back pain and morning stiffness that typically lasts for approximately one hour or less and improves as you begin to start your day. Osteoarthritis is more common in older adults. For individuals suffering with lower back pain after sleeping due to osteoarthritis, pain may be higher in the morning. They may find relief by avoiding stomach sleeping, as this can put more pressure on arthritis joints in the lower back.  While osteoarthritis cannot be cured, symptoms can be managed by remaining physically active and maintaining a health body weight. Importantly, if you are suffering from lower back pain, it does not mean that your back is damaged, but rather that you are sensitive. Indeed, pain is often a poor indicator of tissue harm. To relieve back pain after waking due to osteoarthritis, some individuals may find assuming a flexed posture such as leaning forward or bringing your knees to your chest to be helpful.

Benign Mechanical Low Back Pain (BMLBP)

Benign mechanical low back pain (BMLBP) is one of the most common causes of morning back pain. BMLBP is defined as non-specific back being generated by lower back muscles, bones, ligaments, tendon and/or joints (or a combination thereof). This type of back pain can be described as sharp, stiff and or throbbing. It can extend from the small of your back into the buttocks and/or upper legs. Importantly, this type of back pain does not cause numbness and tingling and does not extend past the knee.

The causes of BMLBP are many.  Lower back pain is often caused by lifting more than you are used to (improper load management) a sudden jerk or movement, a slip or fall, bending over, stress, a lack of activity and/or sleep, and other lifestyle factors. Simply put, multiple factors both physical and psychological can contribute to lower back pain. Importantly, just because you have an episode low back pain that is worse when waking does not mean that your back is weak, and back pain while you sleep is generally not a cause for serious medical concern. Moving, even if painful at first, does not mean you are damaging your back. In fact, moving is one of the best things you can do with an episode of non-specific low back pain.  Additionally, back pain does not mean you put your back out of alignment (this is not a thing), or that your core is weak or your posture is poor. Fortunately episodes of BMLBP are short lived, typically lasting 6 weeks or less.  You can help reduce back pain of this nature by remaining physically active (strengthen your back and body, stretch your back and body, do cardio etc.) pro-actively monitoring stress and sleep, and engaging in health lifestyle habits.

If your back pain persists greater than 6 weeks, it would be classified as chronic back pain.  In this case, speak with the physiotherapists at REP Physio in Edmonton to determine an appropriate plan of care.

How can I relieve back pain when I wake up?

For clients of REP Physio in Edmonton that experience back pain when they wake, we recommend the following:

1. Stay physically active.  The benefits of physical activity for acute and chronic lower back pain is well established. Exercise is a safe and effective pain management tool. If you have a favourite routine, stick to it. If you have a favourite lower back stretch, do it.
2. Reflect on your lifestyle factors.  How are your stress levels?  How is your overall health? Are you significantly overweight? What is your work life balance like.  Multiple studies have shown that lifestyle factors directly impact back pain episodes and their severity.
3. Find a sleeping position that works.  Whether you are a back, side or stomach sleeper, or a little in between, remember to keep a neutral alignment of your spine so your neck or back are supported in a comfortable position.
4. For pain that is worse in the morning, think about your evening routine.  Practice good sleep hygiene. Try to go to bed and wake up at similar times, avoid exposure to screens within 90 mins before bed time and ensure the room temperature is appropriate for your sleep cycle.
5. Your mattress matters. A systematic review conducted in 2021 demonstrated that  a medium firm mattress promoted comfort and sleep quality.¹   Additionally, when mattress shopping, we suggest only trying out one or two mattresses at a time, and be prepared to spend at least 30 mins on any given mattress (bring your favourite pillow and book, seriously). Speaking of pillows, find one that works best for you.  At REP Physio, we carry Pillowise(R) pillows that are custom measured for your body type and sleeping position. To find out more click this link: Pillowise

When should I see a physio for back pain?

Back pain is the most common reason our valued clients attend REP Physio. Fortunately, back pain is rarely a cause for serious medical concern.  If your back pain is preventing you from having a restful sleep, or is stopping you from living your life to the fullest, come to REP Physio. Whether your episode of back pain is acute, or you are dealing with chronic lower back pain, our expert trained therapists can help you manage your back pain, and provide you with an individualized care plan to maximize your function, provide pain relief, and get your back feeling better in the morning.

1.  G. Caggiari et al. “What type of mattress should be chosen to avoid back pain and improve sleep quality?” Review of the literature” J. Orthop Traumatology 2021 Dec8:22(1):51