Pillows for Neck Pain

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Patients with chronic neck pain often inquire about optimal pillow choices. Unfortunately the evidence based in this area is still very weak at the time of writing.

There are a vast array of pillows are marketed with claims of alleviating neck pain and improving sleep. These range widely in material (foam, latex, feathers, water, springs, synthetic fills), shape (traditional, contour, cervical roll, cylindrical), and firmness. The purported goal of an ideal pillow is to support the head and neck in a way that maintains a neutral cervical spine alignment during sleep, thereby reducing biomechanical stress on muscles, ligaments, intervertebral discs, and facet joints

Pillow Material

The rationale for utilizing specific pillows in managing neck pain stems from the goal of maintaining a neutral cervical spine alignment during sleep. An appropriately designed pillow should theoretically support the natural cervical lordosis when supine and prevent excessive lateral flexion when side-lying, thereby reducing biomechanical stress on cervical structures, minimizing muscle activity, and potentially alleviating pain. The concept of an "ideal" pillow often includes characteristics such as appropriate height (commonly suggested around 10 cm), softness, supportiveness, and good thermal properties.

A significant SR/MA published in 2021, analyzed 35 articles up to September 2020, finding 9 high quality studies with 555 patients. These revealed statistically significant differences favoring the use of rubber pillows (including polyester, foam, and latex) over feather pillows with a SMD of -0.182

They also found that spring pillows (SMD -0.539) were effective, however there was only one study (Vanti et al). These are constructed with viscoelastic polyurethane and multiple independent springs designed to adapt to head shape and movement, The SR/MA indicated positive effects for both rubber and spring pillows concerning waking pain reduction, decreased neck disability, and enhanced pillow satisfaction.

While rubber and spring pillows demonstrated efficacy in reducing neck pain upon waking and associated disability, they did not significantly influence overall sleep quality metrics. This suggests that the primary benefit derived from these pillows may relate more to improved biomechanical support and reduced nociceptive input during the night, leading to diminished symptoms upon awakening, rather than a fundamental alteration of sleep architecture or continuity. The mechanism appears centered on providing adequate support to minimize stress on cervical structures during sleep, which manifests as reduced morning pain and stiffness, even if standard sleep quality questionnaires do not capture a significant change.

There was a substantial positive effect observed for patient satisfaction (SMD 1.144) as a clinically relevant outcome with the use of these pillow materials.

One study that was not in the above SR/MA, possibly because it was published around the same time, did not replicate the above results. They found that latex pillows did not perform well on any outcome measure and had higher dropout rates than polyester pillows for adult patients with "radiologically confirmed cervical spondylosis". This is obviously not a clinically useful diagnostic category.

Pillow Shape and Height

Regarding spinal alignment, the 2001 SR/MA found that pillow material (specifically comparing rubber versus feather pillows) did not significantly alter cervical spine alignment when assessed in the side-lying position. Cervical alignment is likely influenced significantly more by pillow shape and height.

Height: The ideal pillow height aims to fill the space between the head/neck and the mattress, maintaining the natural cervical lordosis (slight inward curve) without causing excessive flexion or extension. A height of approximately 10 cm is often cited as a general guideline. The SR/MA mentioned moderate evidence supporting a height range of 7-11 cm for improving sleep quality, spinal alignment, and reducing sleep-related pain. Importantly, optimal pillow height is not fixed; it depends significantly on the individual's sleeping position (typically requiring a higher pillow for side sleeping than for back sleeping to fill the larger gap created by the shoulder) and anthropometry, particularly shoulder width. Studies employing strict, individualized pillow height adjustment have demonstrated significant improvements in both neck pain and related somatic symptoms.

Shape: Various pillow shapes aim to enhance cervical support. Contour pillows, often U-shaped with raised sides and a lower central area, are specifically designed to support the cervical curve when sleeping on the back and to prevent excessive lateral neck bending when sleeping on the side. Other shapes, like cylindrical rolls or pillows with distinct sections, also exist. Research comparing shapes suggests potential differences based on sleeping position; for example, one study found rectangular pillows were more comfortable in the supine position, while cylindrical pillows provided more comfort and lower neck muscle activity (upper trapezius, sternocleidomastoid) in the lateral position.