“There’s no perfect bed for everyone. “
“Everyone is different.”
All of the above statements are true.
Dr. Steven H. Feinsilver, Director of the Center for Sleep Medicine at Lenox Hill Hospital in NYC, says in a piece on Healthline.com, “It’s fairly remarkable that there is not any consistency in the literature where people have looked at it and said ‘this is the kind of bed you need.’”
Indeed, the lack of answers for back pain sufferers is remarkable.
It’s also not very helpful.
So, after much research and hours of conversation with an experienced PT, here’s the bottom line: most people should sleep on the firmest mattress they can find – with three critical caveats:
- You need an egg crate or mattress topper for padding so that your bony prominences (i.e. bursas, joints, etc.) aren’t irritated,
- Your mattress/pillow needs to support your neck properly, and
- You need to be able to fall asleep! Lack of sleep not only makes your back pain worse but it also tangibly disrupts the rehydration and healing that should happen in your spinal discs at night.
Those caveats make every individual’s situation unique. They also explain why experts are hesitant to make recommendations and why some studies seems to throw up their hands and just simplistically recommend medium firm mattresses.
But, rather than giving up, you should:
- talk to your doctor and seek the advice of a medical professional if you think you might be facing a serious medical condition, and
- if you are simply fighting a normal posture and ergonomics battle, you should buy the firmest mattress possible – with the above caveats – so that your spine is maximally supported.
Choosing a Mattress: 18 Important Questions
To assist you in your selection of a mattress, here are 18 important questions you should ask yourself before making a purchase
#1: What’s the cause of your back pain?
It’s estimated that 80% of all back pain is preventable.
So, if you aren’t a senior with underlying health or aging conditions, it’s very likely that your back pain could be greatly alleviated through different habits or a different environment.
Since about ⅓ of your life should be spent sleeping, your bed is a great place to start. Of course, you should always consult your doctor if you have any doubts about your pain — some of the rare conditions are often the most serious.
#2: When did you last purchase a new mattress?
One study found that the average age of participants’ mattresses was 9.5 years.
Not surprisingly, older and cheaper mattresses are correlated with higher rates of back pain.
Furthermore, this meant that nearly everyone who purchased any new mattress saw improvement in their sleep quality. So, if you have an old mattress, just buy something that isn’t saggy and old.
#3: Do you primarily sleep on your back?
If yes, then you definitely need a firm mattress because any softness in your mattress will result in bulging your spine in the exact same way as when you sit all-day.
Also – your pillow should be on the thinner side so that your chin isn’t pressed against your neck…just like it is when you look down at your phone all-day.
#4: Do you primarily sleep on your stomach?
OK, so there are tons of articles that say that sleeping on your stomach can be bad because it puts your neck out of alignment and it takes your spine out of the neutral position.
That said, if you have a very firm mattress to keep your hips/spine in a neutral position and you place your neck on the edge of the pillow so that your neck turn is minimized, you may actually reap some benefits.
How so? Sleeping on your stomach can actually invert the pressure that you normally put on the back/side of your spinal discs via sitting or slouching.
Now, there’s also some articles about stomach sleeping impacting your gut or giving you a puffy face.
To be honest, we don’t have much to say on those points beyond noting that there seems to be very little substantive evidence for that.
#5: Do you primarily sleep on your side?
If yes, then you need a firm mattress to ensure your disc isn’t bulging to the side while you sleep.
You’ll also want to put a good cervical pillow in your pillowcase to support your neck (we recommend the OPTP Cervical Roll from USA-made and PT-trusted McKenzie Institute).
You should also have sufficient top-level padding on your mattress to account for the curvature of your hips.
#6: How wide are your hips?
If your hips are wider, then you’ll want to have more padding via an egg crate like this one or a built-in mattress topper to ensure that your back is properly supported without irritating any of the hip pointer bursas.
But don’t forget: your underlying mattress still should be firm to support you!
#7: Is it a memory foam mattress?
Like we say all the time, we don’t recommend memory foam because it tends to be overly soft and it retains lots of heat.
There is no way around this truth: beds that are made purely from memory foam are generally your worst option. Unfortunately, this includes some of the most common mattresses – like the Tempurpedic.
That’s worth repeating: mattresses that are primarily memory foam can be harmful for your spinal discs because they are too soft.
As one PT outlined it for us, “At night [after a long day of sitting], the spinal discs should invite water back in while we sleep….but, if we are on too soft of a bed, then the disc doesn’t really recover due to the pressure.”
Thus, it’s only OK for the mattress to have memory foam if it’s just a built-in, relatively thin layer on top of the mattress. An example of a layer of built-in padding on top of the mattress is the built-in 2-inch layer of comfort foam on top of the Sleep Number C2 model (which was named the #1 mattress in 2019 by Consumer Reports).
#8: If there is memory foam, is the bed still breathable?
Beds that aren’t breathable are especially frustrating for men who are more likely to get hot at night due to higher resting metabolisms.
Some types of memory foam are equipped with features to enhance breathability. But, in its nature, memory foam isn’t very breathable.
#9: What’s the overall firmness?
Putting aside memory foam, there are other kinds of beds that are still way too soft to support your back. If it’s not on the firmer side of the available options, then it’s not even worth your time.
In our experience (and as one study has shown), beds that aren’t medium firm to very firm are basically guaranteed to have sub-optimal support.
So, choose wisely and always look for the firmest mattresses available. (But don’t forget about our three very important caveats!)
#10: Is this bed big enough for all the pillows I need?
It’s worth noting that sleeping with a pillow between your knees is the preferred way to sleep on your side and extra pillows also require more space.
As one PT told us, “I always recommend that, the bigger the bed, the better. People with back problems often need more support – and this often requires more space.”
#11: Are we about to get pregnant and is this a king-sized mattress?
In short, full body pillows are often the only way that pregnant women can comfortably sleep during their third trimester.
Such pillows help to ensure proper blood flow and they also reduce pressure on the back.
From personal experience, we recommend this very inexpensive and breathable pregnancy pillow on Amazon.
But you’ll need space for it and you might even want space on your bed for a small bassinet like this.
#12: Will you be able to fall asleep on this mattress? What about your partner?
Forget about supporting your lumbar spine… if you can’t fall asleep, then your bed is worthless.
Unfortunately, many people are so used to sleeping on soft surfaces that they need super soft beds. These soft beds can lead to bulging spinal discs and lower back pain over time.
And then guess what? More than 50% of people with back pain report sleeping difficulties. So, if you require a soft mattress to fall asleep, then you should definitely ask yourself…..
#13: Is the firmness of this mattress adjustable?
If you can’t sleep on firmer mattresses, then you should consider a mattress where you can adjust the firmness (like the Sleep Number).
You can then start by sleeping at whatever is comfortable and simply increase the firmness gradually over time.
One PT patient’s wife did this gradual increase over time without him even noticing.
He went from saying, “This is the worst mattress ever” → “This is the best mattress ever.”
#14: Is there a regular foam top or do you have the ability to add an egg crate?
As noted earlier, a thin layer of padding on top of a firm mattress is ideal.
The exact thickness of that padding will vary depending on your hip size, weight, and bony prominences. But, the bottom line is that the mattress should be very firm and then you should either have a built-in layer of padding or an egg crate like this one.
Pro tip: the padding is ideally not memory foam and it should be changed every 1-2 years. This makes add-on egg crates ideal because it can easily be replaced.
#15: What’s the return policy?
If you’ve been using a soft mattress, then moving toward a firmer mattress is the right call.
But, it might take you weeks to get used to it.
So, you need time to decide if the mattress is right for you. Additionally, don’t forget that the effects of a mattress are often cumulative; for better or worse. So, the longer the test drive, the better.
#16: What’s the warranty?
Good mattresses are not cheap.
So, if the mattress is defective or breaks after only a year, then you want to make sure that they will fix it.
You don’t want to sleep on your saggy, old mattress again.
#17: How high is the new bed?
You don’t want it too low or too high.
Obviously, what’s too high or too low varies for everyone.
But, generally speaking, too low = the height of a regular commode and too high = you need a stepping stool to get in bed or you can’t comfortably sit on the edge of the bed to get your socks on.
#18: What do the reviews say?
Like all products that are good for your back, you should take reviews with a grain of salt.
Healthy back habits aren’t always the most fun.
Plus, the positive and negative spinal effects of different mattresses are gradual so people don’t often realize that their mattress is making a difference for better or worse.
Even still, we still think it’s always worth reading reviews.
Mattresses are no different.
OK, one last question: are you ready to make a purchase and improve your sleep?
What kind of mattress is best for lower back pain?
Obviously, it depends on what is causing your back pain.
However – excluding accidents, autoimmune disorders, normal aging conditions, or congenital back defects – the most common, preventable causes of back pain are related to long-term damage to the spinal discs that result in bulging and/or herniated discs.
If you aren’t sure what’s causing your back pain, then it’s highly recommended that you see a medical professional. In the meantime, however, you can click here to read about 10 common causes of back pain.
Is a firm mattress better for back pain?
In short, yes for most people.
The vast majority of people will do better with a medium firm to firm mattress that they can adjust; unless there are extenuating medical conditions typically found or seen in aging populations.
However, don’t forget these three critical caveats!
- Your mattress and pillow need to work together to keep your neck properly supported,
- Your surface-level padding (i.e. egg crate or mattress topper) needs to be soft enough so that your bony prominences and joints aren’t irritated, and
- You need to be able to fall asleep!
Ultimately, while some studies have reported better self-reported pain relief among those who use softer mattresses, the biology of the spinal discs points toward better long-term outcomes via ensuring that the back is properly supported. This means generally avoiding soft mattresses and aiming for firm support.
How do I know if my back pain is from my mattress?
For starters, you can simply use common sense: if your mattress is very soft or unsupportive, it’s very likely that your mattress is at least a contributing factor.
Beyond that, although the effects of a good or bad mattress are cumulative upon the spinal disc, how you feel in the morning can still tell you something. So, if you’ve had your mattress for more than 6 months, then pay attention to how you feel. According to one physical therapist that we consulted, “You should wake up feeling refreshed and rested in the morning. You should feel less back pain in the morning and it should feel the best it will feel all day in the morning. This is true with the notable exception of stiffness from arthritis.”
Side note: with the exception of accidents, autoimmune disorders, or congenital back defects, very few people will experience typical, age-related arthritis until at least their 40s.
What type of mattress do chiropractors and/or physical therapists recommend?
Product reviews and recommendations from trusted physical therapists (who are the ones with the most medical training) tends to be few and far in-between…or it is often suspect.
Based on our discussions with physical therapists and extensive research, we’ve put together what we believe is a solid list of PT-approved ergonomic recommendations.
What about mattresses that recline and raise the legs?
Generally speaking, most people with common disc issues should not get these mattresses that adjust posture because it bulges the disc.
Of course, there are some people who have spinal stenosis who need to be rounded and there are other people who need to elevate their feet because of swelling. But again, it’s like the lesser of two evils.
One final comment: beds that raise can be helpful for some older people who need assistance in exiting their beds.