Adjusting sleep habits and lifestyle habits can help a person with ankylosing spondylitis reduce and manage nighttime pain to get better quality sleep.

Ankylosing spondylitis (AS) is a form of arthritis that causes inflammation in the joints of the spine. Its key characteristics often include persistent back discomfort and gradual stiffening of the back. The discomfort tends to worsen during times of rest or inactivity, causing some people to experience pain while they are sleeping.

According to some research, 35–90% of people with AS report poor sleep. People with AS also experience more serious sleep disorders than people without the condition.

Treatment can help people with AS manage discomfort, preserve spinal movement, and maintain functional mobility.

This article provides some tips to help people with AS improve their sleep quality.

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Persistent sleep problems may indicate ineffective or inadequate management of AS. People who continually experience disrupted sleep due to back pain or other AS symptoms may benefit from talking with their doctor or requesting a referral to a specialist such as a rheumatologist.

Healthcare professionals may prescribe nonsteroidal anti-inflammatory drugs (NSAIDs). They may also give a person a tumor necrosis factor-alpha (TNF-alpha) blocker such as adalimumab or infliximab if NSAIDs do not provide enough relief.

In a small 2018 study that included 34 people with AS, participants — particularly those with higher disease activity — had better sleep quality after anti-TNF-alpha therapy.

The firmness of a mattress can significantly affect the sleep quality of people who have back pain. A bed should help provide enough support for a person’s sleeping posture and maintain the spine’s natural alignment to reduce back pain.

In the past, doctors often recommended extra-firm mattresses to people with back pain. However, a 2021 review suggests that a medium-firm mattress promotes sleep quality, comfort, and alignment.

Extremely firm mattresses may worsen pain because they do not conform to a person’s body and therefore interfere with the spine’s natural alignment. They also lack the necessary “give” near bony prominences, so they put pressure on these structures.

A small 2017 study found that latex mattresses reduced peak body pressure more and helped distribute pressure more evenly than polyurethane mattresses.

Poor spinal alignment during sleep can cause joint pain. Experts recommend sleeping in a position that keeps the spine neutral, supported, and aligned.

Many experts recommend sleeping on the back without a pillow. It is also essential to keep the legs straight rather than bent. Flexing the hip a little by putting a pillow under the thigh can also help keep the spine in a more neutral position.

When sleeping on the side, placing a pillow between the knees can help reduce tension on the hips and lower back.

A small 2020 study noted that people who underwent surgery to correct thoracolumbar kyphosis — a forward curvature of the spine — due to AS had improved sleep quality. And while 89% of those people had supine dysfunction before surgery, only 15% had it afterward.

However, a 2017 study noted that sleeping postures do not seem to affect sleep disturbance or condition activity in people with AS.

A person who has difficulty sleeping in these positions may want to talk with a physical therapist about other options.

Using thick, overstuffed pillows can place the neck and head in an unnatural, hunched posture. Replacing a thick pillow with a thin pillow or no pillow can help maintain good spinal alignment.

People with AS tend to get less physical activity than the general population, and sleep disturbance is more likely in those with low physical activity.

Daily exercise, including postural training and therapeutic exercise, is crucial for strengthening muscle groups to help prevent spinal irregularities from contributing to back pain. It also relieves pain and maintains the spine’s mobility and range of motion.

People with AS may be more prone to sleep apnea due to abnormal inflammatory responses and breathing difficulties because of the limited ability of the chest to expand.

In a small 2009 study involving 31 people with AS, researchers found that 40% of participants ages 35 years and older had obstructive sleep apnea (OSA).

People who have recently received an AS diagnosis are also at a higher risk of developing OSA.

In a 2021 Swedish study, participants who had both AS and OSA had the following characteristics:

Sleep apnea can cause disrupted sleep, excessive daytime sleepiness, and fatigue. Because people with AS tend to have sleep apnea, they should speak with their doctors about getting a sleep assessment.

Pain, stress, and depressive symptoms can prevent a person with AS from getting enough sleep.

According to a 2021 review, relaxation techniques can reduce chronic pain by triggering pain-reducing processes in the brain.

Other research suggests that relaxation techniques can help reduce stress, enhance a person’s state of relaxation at the physiological and psychological levels, and improve overall well-being.

Studies show a tight relationship between AS and gut microbiota. The gut microbiota is essential in maintaining gut health, and changes to it have associations with the development of inflammatory diseases.

The gut microbiota is different in people with AS than in those without the condition. In people with AS, the microbiota has a relationship to diet and AS activity. Research estimates that 50–60% of people with AS have subclinical inflammation of the intestinal barrier, and those with inflamed intestines have higher condition activity.

A high intake of anti-inflammatory foods, such as those with omega-3 polyunsaturated fatty acids and fiber, has an association with lower condition activity, while a high intake of ultra-processed foods can increase condition activity.

Similarly, the results of a 2023 study suggest that dietary fiber intake positively affects AS and its symptoms.

The following are some questions people frequently ask about sleeping and AS.

What is the best position to sleep in with ankylosing spondylitis?

Many experts recommend that people with AS sleep on their back with a thin pillow or no pillow.

Why is ankylosing spondylitis worse at night?

AS symptoms often worsen during times of limited movement and rest, including periods of prolonged sitting and sleep.

What are the coping mechanisms for ankylosing spondylitis?

AS has no cure, but treatment and lifestyle strategies can help people manage it. A person with AS should avoid smoking since it can worsen the symptoms. People should also avoid alcohol consumption, which can speed up spinal structural damage in AS.

A person may take medications for pain relief. Additionally, maintaining mobility and flexibility through regular exercise and good posture can help a person reduce pain and prevent stiffness.

Pain from ankylosing spondylitis (AS) can make it difficult for people to get quality sleep. Ensuring good spinal alignment and posture during sleep and maintaining healthy lifestyle habits, such as regular physical activity and a diet high in anti-inflammatory foods, can help reduce nighttime pain and stiffness from AS.

People who taking medication for AS and still experiencing sleep problems should consider speaking with their doctor for pain management recommendations and a potential referral to a specialist who can help, such as a physical therapist.