Winning Position: how sleeping position affects sleep quality

My experience is that 20 years ago, hardly anyone talked about the importance of sleep. Now, it seems, sleep advice is everywhere. Getting enough sleep is something that I covered in a previous newsletter. But, while quantity of sleep is important, so is its quality.

There are several factors that have relevance here, one of which is sleeping position. While a small number of people opt to sleep on their fronts, I’ve found the great majority of people actually are side- or back-sleepers. Does it make a difference? I think it does.

When we lie on our back, there is a tendency for gravity to pull the tongue and soft palate (the back of the roof of the mouth) backwards, narrowing the airway. For some, the result is snoring. The effect of gravity is much less if someone is on their side. It’s something long-suffering bed partners often notice. And it’s the reason some, when disturbed by their partner's snoring, give them a sharp dig in the ribs with their elbow in an effort to get them to roll over.

If the airway obstruction is bad enough, it can lead to momentary cessation of breathing - what is called ‘obstructive sleep apnoea’. As a result, oxygen levels drop, and the brain jolts the breathing response into life. However, repeated bouts tends to cause sleep quality to suffer a lot. Not uncommonly, those with sleep apnoea wake after what seems like sufficient sleep in terms of hours, but feel as though they’ve hardly slept at all.

As alluded to above, side-sleeping reduces the tendency for their partner to snore. But it can help sleep apnoea, too [1]. This review found that ‘positional therapy’ (using a device to ‘force’ side-sleeping – see below) improved both measures of apnoea severity (the Apnoea-Hypopnoea Index or ‘AHI’) and measures of sleepiness (the Epworth Sleepiness Score of ‘ESS’).

Yesterday, I was perusing X and came across a post from an ENT specialist Dr Mary Talley Bowden who alerted us to the need to take into account body position when interpreting sleep studies for sleep apnoea. She shared the results of a patient who had an AHI of 55 (very severe) when sleeping on his back, but the score was only 3 (basically, normal) when not on his back.

A standard medical treatment for sleep apnoea is Continuous Positive Airway Pressure or ‘CPAP’. This device basically blasts air into the nose or nose and mouth via a mask to force the airway open. These devices can be a godsend in terms of how refreshed someone feels in the morning, but many people do not tolerate them at all well. In any case, in her post, Dr Talley Bowden revealed that instead of prescribing her patient a CPAP machine, she advised him to buy a ‘sleep backpack’ (like the one in the photo below).

This and similar devices are tools used in the positional therapy above, which essentially make it very uncomfortable to sleep on the back. Another example would be a small mesh rucksack with a tennis ball or similar inside. An alternative option would be to sew a pocket into the back of a t-shirt and place a ball inside.

Another approach that can be helpful is to opt for a slim pillow or no pillow at all. The rationale here is that without adequate support for the head, back-sleeping is too uncomfortable, forcing individuals to sleep on their sides or front.

My experience is that these simple and economical approaches can make a big difference to sleep quality for not just the individual who suffers from snoring and/or sleep apnoea, but any bedroom partner as well.