Sleeping with Scoliosis – All you need to know

Sleep is characterized by species-specific posture that minimizes the sensory stimulation, absence of voluntary movements, regulated by homeostatic mechanism and takes place with a circadian rhythm.¹ Reduced sleep quantity and quality has become very common in modern world. Shorter sleep cycles have been found to be deeply associated with different physiological and psychological disorders. Inadequate sleep multiplies the risk of several diseases like depression, obesity, hypertension and coronary diseases. Insufficient sleep can cause disturbance in endocrine, metabolic, immune and inflammatory systems. Recent research has documented a close association between sleep deprivation and lower mineral bone density especially in middle aged and elder females.² Scoliosis is a neurological disorder characterized by lateral curvature of the spine.

This article explores scoliosis, its types, sleep positions and difficulties, management and provides tips for better sleep with scoliosis.

Scoliosis, types and clinical presentation

Scoliosis is characterized by lateral curvature of the spine measured by Cobbs’s angle. Greater the angle above and below the curve of apex, higher is the risk for the progression of disease. Scoliosis is basically divided into two types: i) postural (Grade I), without any muscular weakness or bony changes. It is most commonly due to wrong postural habits or impairment of the postural reflex mechanism. ii) structural scoliosis (Grade II and III), which is caused by defect in bone that leads to convex and concave curvatures in the spine.³

Scoliosis may be present from childhood or young age and can progress with advancing age. It is de novo in adults without any symptoms in childhood.⁴ Based on the cause, scoliosis is mainly classified into, Type 1, Primary degenerative scoliosis, Type 2, progressive idiopathic scoliosis, Type 3, secondary degenerative scoliosis that could be secondary to idiopathic or could be due to metabolic bone disease, mostly osteoporosis or arthritic disease or vertebral fractures.⁵

Scoliosis most commonly presents with four types of curve patterns that includes Thoracic, curves mostly on right side, Lumbar, mostly on left side, Thoracolumbar, curves on right side and Double major, curves that occur both right and left sides.³

The side effects of progressive scoliosis include cosmetic deformity and development of chronic back pain. Extreme progressive curvatures i.e. more than 50 degrees or more than 75 degrees can lead to respiratory problems also.⁴ The presence of sleep associated respiratory difficulties are commonly observed in patients with progressive scoliosis. It causes difficulty in breathing and pain at night, which further leads to impaired quality and quantity of sleep.⁴

The different ways to sleep^6,7

Sleep is an important mechanism in humans, to eliminate fatigue, restore body’s strength and reassure the well functioning of the mind. For healthy subjects during the overnight sleep, different sleeping positions/postures have several effects on the body and its functioning. Every individual is different and their positioning during sleep varies. Following are some of the common sleeping positions and their impacts on human body.

Fetal position

This is the most popular sleeping position.  This loose fetal position, where body lies on side with hunched torso and bent knees helps in reducing lower back pain and aids in achieving better sleep during pregnancy. It increases the circulation and prevents uterus from pressing against the liver. This position also helps in reducing the snoring at night. However, sleeping too tightly in this position could limit deep breathing and can cause soreness in the morning in patients with arthritis and joint pains.

Sleeping on side

Sleeping on side, where the torso and legs are comparatively in straight line helps in reducing the acid reflux and aids in digestion. It also helps the patient with neck and back pains. This position helps in keeping the airways relatively open, reduces the snoring hence helpful for patients with sleep apnea.^8,9

Sleeping on back

Though, this is not the most popular sleeping position, but by far it is the healthiest option. It helps to allow head, neck, back and spine on rest in a neutral position. This prevents extra pressure on any portion of body and helps in regulating acid refluxes. However, in cases of snoozing it can cause the tongue to block breathing, which could be dangerous for the patients with sleep apnea.^10,11

Sleeping on stomach

Well, its easy to snore in this position, but it is practically bad for everything else. Sleeping on stomach could cause increased pressure on muscles and joints, causing numbness, aches, tingling and nerve compressions. This position also increases the pain in both neck and back.

Effect of scoliosis on sleep

In adults, the clinical presentation of scoliosis is characterized most commonly by presence of back pain. It can be localized ether at the apex or around the concavity or can be radiating towards the leg. The unbalanced, overloaded, and stressed muscles of back become sore under continuous pressure and highly contribute to back pain.⁵ Various aspects of sleep are known to be adversely affected by the presence of pain including sleep duration, quality, efficiency, onset and activity or movement during sleep.

Multiple studies have recorded the effect of sleep deprivation on the presence of next day fatigue, mood disturbances, lack of concentration, memory function, work performance and other daily activities.¹² Li H, et al. (2011) reported decreased sleep duration as a risk of progressive degenerative scoliosis. Degenerative Lumbar Scoliosis (DLS) develops after skeletal maturity and characterized by Cobb angle of more than 10 degrees in the coronal plane. They presented osteoporosis and intervertebral disc degeneration (IDD) as two major risks associated with progressive DLS. The increased glucocorticoid level during day, early evenings and inflammatory markers such as IL-1 and IL-6 can cause deprivation and alteration of sleep duration.²

Scoliosis is a 3-dimensional deformation abnormality of spine with direct effects on the thoracic cage, which could impair the respiratory functions by limiting the chest wall movements. As a result, it could disturb the sleep breathing with increased episodes of apnea, hypopnea and insufficient ventilation of the lungs during sleep leading to disturbance in quality and quantity of sleep.¹³ Similarly, MacKintosh EW, et al. (2019) also mentioned the increased incidence and prevalence of sleep abnormalities in children diagnosed with Early-Onset Scoliosis (EOS) that could lead to improper growth and development of children with EOS.¹⁴

Depending upon the type of scoliosis, intra-operative management includes anterior or posterior correction surgeries. Chronic or persistent pain is commonly recognized as an unavoidable consequence in a number of surgical disciplines. The occurrence of post-operative pain is usually associated with management of scoliosis by distraction used in posterior correction spinal fusion.² This type of chronic or persistent pain is different from the initial acute post surgical pain. It is more consistent and mostly neuropathic in nature involving central sensation at the dorsal horn of the spinal cord. As discussed earlier, despite the use of analgesics, chronic or persistent pain is generally associated with disrupted sleep patterns and reduced durations.¹⁵ Rehberg S, et al. (2008) also reported the presence of sleep disturbances in patients managed surgically for the spinal correction surgery. ¹⁶

Management and tips for better sleep with scoliosis

Treatment or management of scoliosis depends on the functional and physiological impairments. During the onset of scoliosis, the central nervous system treat the abnormality by itself, but with passage of time habituation occurs and brain treats it as normal.

“The conservative approach for the management of scoliosis includes exercises and postural retraining.”

Depending upon the angle of curvature and progression the management comprises through observational, corset bracing and last surgery.²

As mentioned earlier, back pain or lower back pain is the most common clinical manifestation of scoliosis. To decrease the pain in back, relax the muscles and to get a better quality sleep, sleeping on the back or supine position is considered optimal. Sometimes scoliosis is associated with obstructive breathing issues, causing additional pressure to the thoracic cage. In such situations, sleeping on side can be more helpful. Along with the right sleeping posture, a medium-firm mattress with sleep accessories such as pillows to balance the curves aids in relieving the back pain and improves the overall quality and duration of sleep.¹⁷

Conclusion

Sleep is the reset mechanism of human biological clock. It helps in restoring energy, eliminating fatigue and cognitive functioning. Scoliosis is a multifactorial disorder characterized by lateral curvature of the spine. Scoliosis does not have immediate signs or symptoms. With the progression of disease, it leads to chronic back pain and respiratory obstructions. Correct sleeping posture and lifestyle modifications aids in relieving the pain and improving the overall quality of sleep in patients with scoliosis.

References

1. Frank MG, Heller HC. The Function(s) of Sleep. Handb Exp Pharmacol. 2019; 253:3-34. doi:10.1007/164_2018_140
2. Li H, Liang C, Shen C, Li Y, Chen Q. Decreased sleep duration: a risk of progression of degenerative lumbar scoliosis. Med Hypotheses. 2012;78(2):244-246. doi:10.1016/j.mehy.2011.10.036
3. Shakil H, Iqbal ZA, Al-Ghadir AH. Scoliosis: review of types of curves, etiological theories and conservative treatment. J Back Musculoskelet Rehabil. 2014;27(2):111-115. doi:10.3233/BMR-130438
4. Rosenberg JJ. Scoliosis. Pediatr Rev. 2011;32(9):397-398. doi:10.1542/pir.32-9-397
5. Aebi M. The adult scoliosis. Eur Spine J. 2005;14(10):925-948. doi:10.1007/s00586-005-1053-9
6. Pan H, Xu Z, Yan H, et al. Lying position classification based on ECG waveform and random forest during sleep in healthy people. Biomed Eng Online. 2018;17(1):116. Published 2018 Aug 30. doi:10.1186/s12938-018-0548-7
7. Hsia CC, Liou KJ, Aung AP, Foo V, Huang W, Biswas J. Analysis and comparison of sleeping posture classification methods using pressure sensitive bed system. Conf Proc IEEE Eng Med Biol Soc. 2009;2009: 6131-6134. doi:10.1109/IEMBS.2009.5334694
8. Penzel T, Möller M, Becker HF, Knaack L, Peter JH. Effect of sleep position and sleep stage on the collapsibility of the upper airways in patients with sleep apnea. Sleep. 2001;24(1):90-95. doi:10.1093/sleep/24.1.90
9. Szollosi I, Roebuck T, Thompson B, Naughton MT. Lateral sleeping position reduces severity of central sleep apnea / Cheyne-Stokes respiration. Sleep. 2006;29(8):1045-1051. doi:10.1093/sleep/29.8.1045
10. van Herwaarden MA, Katzka DA, Smout AJ, Samsom M, Gideon M, Castell DO. Effect of different recumbent positions on postprandial gastroesophageal reflux in normal subjects. Am J Gastroenterol. 2000;95(10):2731-2736. doi:10.1111/j.1572-0241.2000.03180.x
11. Joosten SA, O’Driscoll DM, Berger PJ, Hamilton GS. Supine position related obstructive sleep apnea in adults: pathogenesis and treatment. Sleep Med Rev. 2014;18(1):7-17. doi:10.1016/j.smrv.2013.01.005
12. Kelly GA, Blake C, Power CK, O’keeffe D, Fullen BM. The association between chronic low back pain and sleep: a systematic review. Clin J Pain. 2011;27(2):169-181. doi:10.1097/AJP.0b013e3181f3bdd5
13. Li X, Guo H, Chen C, et al. Does Scoliosis Affect Sleep Breathing?. World Neurosurg. 2018;118: e946-e950. doi:10.1016/j.wneu.2018.07.106
14. MacKintosh EW, Ho M, White KK, et al. Referral indications and prevalence of sleep abnormalities in children with early onset scoliosis. Spine Deform. 2020;8(3):523-530. doi:10.1007/s43390-020-00080-x
15. Wong GT, Yuen VM, Chow BF, Irwin MG. Persistent pain in patients following scoliosis surgery. Eur Spine J. 2007;16(10):1551-1556. doi:10.1007/s00586-007-0361-7
16. Rehberg S, Weber TP, Van Aken H, et al. Sleep disturbances after posterior scoliosis surgery with an intraoperative wake-up test using remifentanil. Anesthesiology. 2008;109(4):629-641. doi:10.1097/ALN.0b013e31818629c2
17. Radwan A, Fess P, James D, et al. Effect of different mattress designs on promoting sleep quality, pain reduction, and spinal alignment in adults with or without back pain; systematic review of controlled trials. Sleep Health. 2015;1(4):257-267. doi:10.1016/j.sleh.2015.08.001