Considerations in Mattress Recommendations

By Mark Mandell, DC, MBA
Dr. Mandell is a third-generation chiropractor who practices in Metuchen, N.J., and provides health-care consulting to chiropractic-related businesses. He is also the co-founder and managing partner of Chiropractic Mattress Education.

One in seven Americans buys a mattress each year1 - in 2001, 38.7 million mattress units were sold.2 Patients recognize that selecting the right mattress can help their back and neck, but getting information on how to select the right mattress is nearly impossible. With nowhere else to turn, most consumers use their mattress salesperson as their primary resource. However, without any health care training, the salesperson has to rely on the consumer's perception of mattress comfort based entirely on a "mattress-test-drive" in the middle of a store for 30 seconds. According to the Better Sleep Council, consumers have shown a growing confusion and anxiety with mattress shopping that discourages them from completing the purchase and leads many to keep their old, worn-out mattresses.


What complicates matters even more is that most mattress companies use private labeling to prevent comparison price shopping from store to store. Consumers cannot find the same mattress in each store to compare, because each store sells it under a different product name or model number. Comparing mattress features, such as coil count, also is impossible, because it disregards the different gauges of steel used in the construction. The lower the gauge, the stronger the coil. Therefore, some mattresses can have high coil counts, but use lower-quality steel (higher-gauge). The result: decreased support.


Trying to quantify the quality of foams and padding could inform someone with an engineering degree, but density and type mean nothing to the average consumer. Some people think a longer warranty indicates a better mattress, but sometimes, the manufacturer extends a warranty for that very marketing purpose, without necessarily improving the quality of the mattress. Even Consumer Reports has balked at rating mattresses, because it was impractical to provide an accurate method of cross-comparison with the multitude of subbrands. Here's the best advice mattress organizations can provide on how to select a mattress: Lay on it with your significant other.


From a chiropractic perspective, mattresses are health care products that can retain the natural position of the spine and reduce subluxations when properly fitted. A prescribed bedding system can reduce back pain by 57%; decrease back stiffness by 59%; and improve the quality of sleep by 61%.3 Patients ask their doctors for assistance with mattress selection, but few doctors were ever trained in sleep systems.


As chiropractors, we are well-positioned to extend our knowledge of the spine and help patients select sleep systems, in much the same manner we do with pillows, back supports and orthotics. An informed DC should ask patients about the status of their mattresses as part of their spinal health care, discussing the following information:


Important Mattress Characteristics


1. Inner spring mattresses represent 86 percent of all mattresses sold, and reportedly provide optimal support of the neck, back, shoulders and hips combined.4 They are also the most commonly recommended type of mattress by chiropractors, medical doctors and physical therapists. Flotation beds (including waterbeds and hybrid waterbeds) comprise 6 percent of mattress sales. Air beds and pure foam mattresses each tally only 3 percent of sales.5,6


2. Mattresses and box springs are usually sold as a set because they are designed to work together for optimal support and comfort. This is not a selling tool by the mattress salesperson to "pad" his or her commission. It is important to replace both the mattress and box spring when a new mattress is purchased. Some manufacturers will even void the warranty on a mattress if it is not set up on the matching box spring.


3. It is also important to understand the basic terms used in the bedding industry. Firmness is the bedding industry's term for stiffness. Mattress companies do not construct hard, stiff beds, but they do manufacture firm and extra firm beds that provide support to the spine. Firmer beds don't necessarily have higher coil counts or stronger gauges of steel, but often have stiffer padding and foam. A box spring also can provide added firmness to a mattress based on its construction.


4. Similarly, "plush" is the bedding industry's term for "soft." An extra level of plushness can be incorporated by adding a pillow top: an extra layer of padding sewn onto the top of the mattress. The word "plush" is most often associated with "comfort," although in better bedding systems, comfort and support are provided together. By combining high coil counts, low-gauge steel, quality foams and premium padding and quilting, luxury bedding product lines can meet the complex needs of consumers, particularly those who have a multitude of health issues.


5. There are over a thousand mattress manufacturers in the U.S., and many of them make multiple brands. Many brands have similar features, although they utilize different names and patents to project a unique marketing image. Doctors should be cautious about recommending a particular brand or manufacturer unless they are wholly knowledgeable about the mattress line, because of the likelihood of a mix-up at the point of purchase.


Before fitting a patient for a mattress, it is important to review the patient's standard health history, as well as his or her sleep history. The health history helps to identify problem areas in the body that may need added support or comfort and certain systemic problems, such as circulatory disorders, that may require specialized bedding. The sleep history should include the patient's preferred sleeping positions; current types of mattresses and any problems with them; how often the patient wakes up with back and neck pain or stiffness; an explanation of his or her bedtime rituals; and descriptions of sleeping environments. Postural analysis and a chiropractic physical examination also may provide necessary information for a mattress recommendation. Identifying particular health care problems in this process also can lead the doctor to recommend other forms of treatment, such as rehabilitative exercises or spinal- or pelvic-stabilizing orthotics.


Health and Sleep Characteristics


Chiropractors need to address the following health-care and sleeping-position issues when recommending a mattress to a patient:


Lower back pain: Patients suffering with low back pain (LBP) most often prefer beds that are firmer. One study purported that hard beds should be the first choice for LBP sufferers, but if that did not help, then they should try waterbeds.7 The recommendation is not that they should sleep on a rock-hard bed, but rather, that they need support. A firmer bed prevents the low back from sinking deeply into the bed and irritating the facet joints. Higher-end luxury beds can provide plenty of support along with comfortable padding, while lower-end discounted beds can provide the firmness, but with less comfort.


Upper back and neck pain: Patients who are suffering from upper back and neck pain often prefer softer or plushier bedding. The plushier cushioning in the bed allows the head and thoracic area to sink into the bed to support the cervical area. A pillow-top mattress, or one with softer foams, padding and quilting, can be a good recommendation. There are also several types of pillows that can provide extra support for the neck.


Arthritis and fibromyalgia: Patients suffering with multiple painful joints often prefer bedding with cushioning that disperses the weight across the greatest body surface. Frequently, such patients also have spinal complaints. Balancing cushioning with proper support for the spine requires a higher-end mattress. Since fibromyalgia is related to stress levels, it also is important to review pre-sleep rituals with patients to help relax them before going to bed.


Stomach sleepers: Sleeping on the stomach in a soft bed can stress the thoracolumbar spine. The weight of the belly and pelvis also compress the bedding. To provide support to the stomach, pelvis and thoracolumbar areas, a firmer mattress is necessary.


Side-lying sleepers: An estimated 73 percent of the population sleeps on its side.8 Plush mattresses are often recommended to side-lying sleepers because they provide the best way to maintain the natural shape of the spine and the curves of the hips and shoulders while sleeping. Plush bedding will cradle the body and help disperse the weight of the body across the maximum surface area, instead of creating pressure points at the hips and shoulders. Special pillows also may be necessary to support the neck in a position parallel to the ground.


Seniors: Most seniors grew up sleeping on extremely stiff beds, because that was what manufacturers made at that time. Having slept on firm mattresses their entire lives, many prefer firmer bedding, even if their health conditions indicate that plushier bedding would be better. Some education may be necessary to convince an older person of the need to change mattresses.


Consulting with patients about mattress purchases can be a wonderful adjunctive service in a chiropractic office. Chiropractors are the best resource a person has in choosing the right mattress. As part of the chiropractic total health-care paradigm, each patient should receive this extra level of care for the improvement of his or her spine and overall quality of life. After all, a good night's rest can do wonders for the mind, body and soul.




  1. 2001 U.S. Mattress Industry Annual Report and Sales Statistics. International Sleep Products Association, July 2002, Alexandria, Va.
  2. Ibid.
  3. Jacobson BH, et al. Effectiveness of a selected bedding system on quality of sleep, low back pain, shoulder pain, and spine stiffness. Journal of Manipulative and Physiotherapeutic Therapies, 2002 Feb;25(2):88-92
  4. "What's the Best Sleeping Surface? The Results are Firm." Consumer brochure. American Innerspring Manufacturers, Memphis, Tenn., 2000.
  5. International Sleep Products Association (ISPA), 2002.
  6. Home Furnishing News, 2002.
  7. Garfin SR, Pye SA. Bed design and its effect on chronic low back pain - a limited controlled trial. Pain 1981 Feb;10(1):87-91.
  8. Addison R, Berland T. Living With Your Bad Back. New York, St. Martin's Press, Inc. 1984.
Mark Mandell, DC, MBA
Metuchen, New Jersey

Mark Mandell, DC, MBA is a third-generation chiropractor and the president of The Vitality Depot, a chiropractic supply company. In addition to his DC degree, he has an MBA in management and a BS in consumer economics Dr. Mandell can be reached at 866-941-8867 or by e-mail at for more information.

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