Occupational Therapy Sleep Hygiene: Choosing the Right Mattress Firmness & Other Tips for Back Pain


We all know how important sleep is to our health. We wrote a post on some tips to improve your sleep hygiene for a better night’s sleep. Many people may take sleeping aids to help them sleep. Another important consideration is the mattress that you sleep on. An old or inadequate type of mattress can lead to back pain and a poor night’s sleep. Finding a mattress can be overwhelming and difficult.

What can make it so difficult?

There is no one perfect mattress for everyone. It can be very subjective. Consumers have many options to choose from. There are traditional, hybrid, and new materials to choose from. To find the mattress for you, it is still to best to try it for a long time. Not just 15 minutes in a mattress store but overnight and for several nights. How do you do that amist a pandemic and when mattress stores only allow you to lay on a mattress for less than 20 minutes? You may want to consider buying a mattress online. But shouldn’t I try it first? Purchasing a mattress online can be an option as many offer trials, free delivery, and free returns.

Cost is another factor and can range from economical to the super expensive sub $10,000 for a bed like the Sleep Number. Add to this sketchy reviews from Affiliates and Influencers who may be compensated and you do not know who to trust.

Back Pain

If you have back pain, it is important that you understand the research first when deciding on mattress firmness.

Firmness Myth

Firm mattresses are better for back pain?

For the longest time, I believed this to be the case. My family switched out their beds for the firmest ones only to put memory foam on top of it down the line. We recently visited two different types of mattress stores and both sales associates claimed that firm mattresses were better for back pain. Many popular YouTube mattress reviewers make the same blanket statements claiming the same thing. Not surprisingly, mattress review blogs and Reddit comments say the same thing.

Research on Mattress Firmness

Evidence-Based Research actually says the opposite:

  • At 90 days, patients with medium-firm mattresses had better outcomes for pain in bed (Kovacs, 2003).
  • When compared with the hard mattress, the water bed and foam mattresses had a more positive influence on back pain and ADL performance (Bergholdt, 2008).
  • A systematic review on the “effect of different mattress designs on promoting sleep quality, pain reduction, and spinal alignment in adults with or without back pain” revealed that:
    • Medium-firm mattresses are beneficial for individuals with chronic nonspecific low back pain and were rated as more comfortable than soft bedding systems. Studies have shown that medium-firm mattresses improve sleep quality by 55% and decrease back pain by 48% in patients with chronic low back pain.

My Research

My anecdotal evidence says something similar when I looked up my uncomfortable mattress of five years that may have contributed to back pain to find that it is a firm one.

Sleep Number
Credit: Sleep Number

If you ever walked into a Sleep Number store, it is quite insightful as they have pressure mapping to see the locations on the body where you have the most pressure. I was most uncomfortable starting from the firmest setting (100) and preferred a setting around 25 (softer). However, despite trying out all the mattresses available at Sleep Number, I still had some low backpain – no matter the “sleep number” firmness setting. While a Sleep Number bed may be overpriced to some, it may be a consideration for you and your partner if you both prefer different firmness levels. Ultimately, I decided not to purchase one due to cost vs. comfort benefit.

Spine Support
Credit: Realmattressreviews

Mattress Properties and Considerations

  • Types – traditional innerspring, hybrid, air, water, memory foam, latex. No one is superior to another. I recommend you try them all.
  • Support – have someone check your spinal alignment from the side angle
  • Pressure Mapping – visual biofeedback of pressure map, e.g. green-yellow-red of your body on a surface (like how they show you in Sleep Number stores). Unfortunately, the average person does not have access to this tool. Some YouTubers such as Sleepopolis show different pressure maps for people in the light/medium/heavyset sizes, but keep in mind that everyone’s body, including yours – is different. Therefore, pressure relief is different. In an ideal world, you would be able to try out different mattresses and pressure map them all to see if there are any trouble spots.
  • Firmness – if you have back pain, research states that you may be more comfortable on a medium-firm than a firm mattress. There is a difference between firm support (not what you want) and firm feel (okay).
  • Temperature – cool & hot. Some materials may sleep warmer and/or cooler than others. For example, the Purple mattress supposedly sleeps cooler due to having larger and multiple air pockets under the sleeper.
  • Edge Support – do you roll off the edge when sleeping on there due to poor support? If you sit on the edge of bed often, e.g., to put on shoes or pants, you will want good edge support. Test this out.
  • Motion Transfer – a property that affects whether you wake your partner up when you roll or get out of bed. Have your eyes closed and test this by having your partner roll or move in bed.
  • Adjustable Frames – similar to how hospital beds can raise and lower the head and legs. Maybe a worthwhile investment as this can help alleviate back pain.
  • Off-gassing / VOC – does the bed release odors when first deployed (mostly unharmful).
  • Materials – For example, eco-friendlier options such as those that are Greenguard certified.

Sleep Positions

  • Back – the best position for low back pain. Consider placing pillows under your knees for added comfort.
  • Side & Fetal – consider placing pillows between your knees
  • Prone (belly)

Purchase Considerations

  • Trial Period – the longer the better. Some companies (online) even offer generous 1-year trials.
  • Warranty – consider this if purchasing an adjustable frame which will contain a motor. Keep in mind the chance that some newer less-established companies may not “be around” to service your warranty
  • Return policy
    • Beware and read the fine print. For example, the frame on Sleep Number beds is nonrefundable.
  • Mattress protector – don’t forget to buy one to protect the mattress itself from spills and accidents.
  • Watch out for marketing gimmicks, e.g. “orthopedic”, “medically-approved”.


With the current pandemic, it may not be the best idea to go to a mattress store to try out a new mattress. If you still test some out, I will say that many mattress stores are making a good effort with social distancing and using disinfectants.

Alternative: Online sleep trials

Nowadays, many things can be purchased online – even mattresses. Consumers can even buy mattresses termed “bed in a box” which are packed smaller and expand to full size, similar to memory foam. Since online retailers may not have physical presence in a brick and mortar store, they offer many generous sleep trials and free returns and refunds. This also lowers the price as there are no costs for commissions for store associates. If you are environmentally conscious, read reviews on how these companies handle your returned mattress as some may end up in a dump instead of being donated or repurposed.

My List

This is a list of companies that make mattresses that were on my top consideration list.

I was not paid to mention them, but as always, do your own research before buying. Here’s a good place to start:

  • Sleep Number – if you have the budget, many people like the adjustable firmness feature. However, many people consider this to be an overpriced air bed.
  • Mattress Firm Stores (previously known as Sleep Train) – a good option as you can try out different mattresses in person with reputable brands like Serta, Beautyrest, Tempurpedic. May pay a premium – try negotiating.
  • Brooklyn Bedding
  • Casper
  • GhostBed
  • Leesa
  • Helix
  • Purple – tends to sleep cooler; new type of material that many people like.
  • Winkbeds


Consider getting a new mattress if you have been having back pain. One of the most important properties to consider is firmness. Studies have shown that a medium-firm is better than a firm for low back pain. Comfort is mostly subjective so you should trial a mattress for several nights before deciding whether to keep it. Also consider other mattress properties such as edge support, temperature, and motion isolation. Is your mattress getting to be too old? While mattress shopping can seem overwhelming, don’t lose any “sleep” over buying a new mattress – just try before you buy, or trial before you keep!


Bergholdt K, Fabricius R, Bendix T. Better backs by better beds? Spine.2008;33(7):703–708.

Kovacs, F. M., Abraira, V., Peña, A., Martín-Rodríguez, J. G., Sánchez-Vera, M., Ferrer, E., … & Zamora, J. (2003). Effect of firmness of mattress on chronic non-specific low-back pain: randomised, double-blind, controlled, multicentre trial. The Lancet362(9396), 1599-1604.

Radwan, A., Fess, P., James, D., Murphy, J., Myers, J., Rooney, M., … & Torii, A. (2015). 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 health1(4), 257-267.