Mattress Firmness for Back Pain in Later Life

What the evidence says

Studies comparing mattresses for chronic low back pain have generally found that medium-firm mattresses perform as well as or better than very firm ones for pain and for sleep comfort, though results differ among people and studies are limited. Very soft mattresses that let the body sink can let the spine sag, while very hard mattresses can press on the shoulders and hips and cause pain at pressure points. Firmness is a personal preference, and the "best" mattress is one that keeps the spine in a fairly neutral line and feels comfortable to the individual. A doctor or physiotherapist can help work out which factors matter for your parent. For guidance on managing low back pain in general, see lower back pain in older adults.

A mattress cannot treat the causes of back pain such as arthritis, osteoporotic fractures, disc problems or muscle weakness. It is one piece of a plan with movement, strength, medicines and posture.

What a good sleeping surface does

• Supports the natural curves of the spine when lying on the back or side, without letting the hips sink or the shoulders jam.
• Relieves pressure on the shoulders, hips, heels and tailbone.
• Allows movement. A person should be able to turn over and get out of bed without a struggle.
• Has a firm edge for sitting on and standing from.
• Is breathable and cool, important in Indian heat.
• Is in good condition, not sagging or lumpy.
• Suits the bed base, which should be solid, flat and strong.

Types of mattress

Coir (coconut fibre) mattress. Common in India, often firm to very firm, durable and breathable. Good for those who like a firm feel. Can be too hard for a frail or thin person, and can lose shape over time. Look for coir with a latex or foam layer for comfort.

Foam mattress (high-density polyurethane). Widely used, from soft to firm. Quality depends on density: low-density foam sags and develops body hollows within a year or two. Higher density holds shape longer. Choose thickness of 6 to 8 inches or more for a primary mattress, as foam thinner than that may allow a person to feel the base.

Memory (viscoelastic) foam. Moulds to the body and spreads pressure. Good for some with joint pain or pressure points, but warm in hot climates and slow to respond, which can make turning harder for frail or weak people. Check that it is not too soft for getting out of bed.

Latex mattress. Natural or synthetic latex gives a springy support, is long-lasting and often cooler than memory foam. Heavier, and may cost more. Allergies to latex are possible.

Spring mattress. Innerspring or pocket spring with layers of foam. Pocket springs move independently, giving more contouring. Cheaper spring mattresses may sag and feel hard on the edges.

Orthopaedic mattress. A label, not a standard. It may mean a firm mattress, a medium-firm one or something else. Ask what is meant, and check the construction and your own comfort.

Hybrid mattress. Springs with foam or latex on top; good for many.

Air or pressure-relieving mattresses. For people at risk of pressure sores or who spend long periods in bed; see air mattresses for pressure sores and choosing an anti-bedsore mattress.

Futon, floor bed or charpai. Traditional beds may suit some people, but for older adults with stiff joints, a floor bed or a very low bed is hard to get in and out of.

Choosing firmness for your parent

There is no formula, but these points help.

• Body weight. A heavier person generally needs a firmer mattress to avoid sinking, and a lighter person may find a firm mattress too hard because they do not compress it. Thin older adults with bony hips and shoulders often do better on a mattress with some give.
• Sleeping position. Side sleepers need enough give to let the shoulder and hip sink, with the spine straight. Back sleepers need support under the lower back. Front sleeping can strain the neck and back, and is hard for many older people.
• Type of pain. Pain worse in the morning and easing with movement is common with osteoarthritis. Pain from a fracture needs medical assessment. Pain from pressure points on the hips and shoulders may be helped by a softer top layer.
• Skin and pressure risk. A very hard mattress is hazardous for a frail, thin or bedridden person; see preventing bedsores at home.
• Ability to move. Too soft makes turning and rising hard.
• Heat. Choose breathable materials in the Indian climate; see temperature and ventilation at home.
• Bed and edge. The mattress edge should hold up when a person sits.

For most older adults with ordinary back aches, a medium to medium-firm mattress in good condition is a sensible start.

Testing a mattress

If possible, try before buying. In a shop:

1. Lie on the mattress for at least 10 minutes in your usual sleeping position, wearing comfortable clothes. Do not rely on a quick sit. 2. Check the spine: lying on the side, someone should look from behind to see if the spine is straight. On the back, a hand slid under the lower back should find a small gap, not a big one or none at all. 3. Roll over. Is it easy? 4. Sit on the edge and stand up. Does it hold? 5. Check for heat build-up. 6. Ask about the return or trial policy, since a mattress may feel different after a few nights. A reputable seller allows a trial period or exchange. 7. Ask for the foam density, thickness, materials and warranty.

If your parent cannot go to the shop, ask for a sample or trial, and see if you can return the mattress if it is unsuitable. See equipment returns, warranty and servicing.

Fixing a mattress that is not quite right

You may not need a new mattress.

• Too hard: add a topper of medium-density foam, latex or wool, of 5 to 8 cm. Do not add egg-crate foam for pressure care.
• Too soft or sagging: a firmer topper or a board under the mattress may help temporarily, but a sagging mattress is usually a sign it needs replacing.
• Flip and rotate the mattress if the maker allows it, to even out wear.
• Check the base. Slats may be broken or too far apart. A solid base that matches the mattress supports it.
• Use pillows: a pillow between the knees for side sleepers, under the knees for back sleepers, a small roll under the waist; see pillows for side sleepers and shoulder pain and lumbar cushion guide.
• Neck support: a pillow of the right height; see neck pillow guide.
• Replace the mattress if it is more than eight to ten years old, has body hollows, lumps or broken springs, or if the person wakes in pain and sleeps better elsewhere.

Positions and habits

• On the back: a pillow under the knees reduces lumbar strain.
• On the side: knees slightly bent with a pillow between them, and a small cushion behind the back if needed.
• Getting up: roll onto the side, push up with the arms and swing the legs down; see bed height and getting out of bed.
• Morning stretches: gentle, as taught by a physiotherapist; see stretching for stiff older bodies.
• Daytime activity strengthens the back and reduces night pain; see exercise at home for seniors.
• Warmth: a warm bath or heat before bed may ease stiffness, with care for skin; see hot pack safety for older skin.

Warning signs

A mattress is rarely the cause of back pain with:

• pain after a fall or minor injury, which may be a fracture (see osteoporosis home care guide);
• pain that is severe, constant or worse at night, even when resting;
• numbness, weakness or tingling in the legs, difficulty walking;
• loss of bladder or bowel control;
• fever, unexplained weight loss or feeling unwell;
• pain that spreads down the leg; see spinal stenosis and sciatica.

These need prompt medical review.

When to ask a professional

See a doctor for new, severe or persistent back pain, or any of the warning signs above. A physiotherapist can assess posture and movement, teach exercises and advise on sleeping positions and mattress. An occupational therapist can advise on bed set-up and transfers. A nurse can advise on skin and mattress for people who spend long hours in bed.