Sleep Health xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

Sleep Health
Journal of the National Sleep Foundation

journal homepage: http://www.elsevier.com/locate/sleh

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
Ahmed Radwan, PhD ⁎, Philip Fess, BS, Darcy James, BS, John Murphy, BS, Joseph Myers, BS,
Michelle Rooney, BS, Jason Taylor, BS, Alissa Torii, BS
1600 Burrstone Rd, Physical Therapy Program, Utica College, New York, 13502

a r t i c l e i n f o a b s t r a c t

Article history: A significant number of US citizens lack appropriate sleep for several reasons. Back pain has been identified
Received 23 February 2015 as possible cause for inappropriate sleep in adults. Previously, the quality of mattresses and bedding sys-
Received in revised form 13 May 2015 tems has been correlated to the pain perceived by individuals. However, there is controversy in the litera-
Accepted 31 August 2015
ture regarding the type and characteristics of a mattress that best serve the purpose of decreasing spinal
Available online xxxx
pain, and improving spinal alignment and quality of sleep. This study gathered the best available evidence
Keywords:
in the literature related to this matter through conducting a systematic review of controlled trials that were
Mattress design published since the year of 2000. In those trials, mattresses were subjectively identified as soft, medium
Ergonomics firm, firm, or custom inflated. Articles examining the effect of temperature alterations of mattresses on pro-
Spinal alignment moting sleep quality and reducing pain were included as well. Twenty-four articles qualified for inclusion
Pain into this systematic review. The methodological quality of the reviewed clinical trials was deemed moder-
Sleep quality ate to high according to the PEDro scale. Results of this systematic review show that a mattress that is sub-
jectively identified as a medium-firm mattress and is custom inflated (self-adjusted) is optimal for
promoting sleep comfort, quality, and spinal alignment. Evidence is not sufficient yet regarding the appro-
priate temperature of the optimum mattress; however, warm temperature has been recommended by
authors.
© 2015 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.

Introduction The harmful impacts of sleep deprivation, such as impairments in

cognitive and motor performance or the negative effects on social in-
Sleep is an important part of our lives, with approximately one- teractions, mood, and quality of life,5 are reasons enough to research
third of our life spent sleeping,1 but in the United States, it is estimat- which is the best mattress available on the market. Although numer-
ed that more than 70 million individuals have trouble sleeping, with ous studies recognize the importance of a sleep surface on sleep qual-
this number only expected to rise. 2 Although 7 to 8 hours of sleep a ity, there is great controversy on what surface design is the optimum
night is preferred, the average adult in America gets less than 7 for the relief of neck or back pain. In terms of mattresses, some studies
hours of sleep a night, with 26% of Americans reporting a good night’s provide evidence that foam bedding designs can actually create symp-
sleep only a few times per month.2,3 toms of back pain, whereas other studies claim that medium-firm sur-
Lack of sleep can impact an individual’s quality of life, social faces can actually lower pain in individuals with back problems 2,6.
interation, and mood. 2 Sleep deprivation can also cause a decrease Manufactures of mattresses claim that there are health benefits to
in work productivity, greater number of sick days used, and increased using a particular sleep surface but have insufficient research to sup-
injury rates, with 56,000 motor vehicle crashes being a result of port these claims2,7.
sleepiness due to a 50% slower response time and decreased The limited research on the subject and the large discrepancy in
accuracy.2,4 the literature further support the need for continued investigation
into what sleep surface is the best for relief of pain. The purpose of
this systematic review was to assesses all available clinical trials
pertaining to the effect of different types of mattresses on reducing
⁎ Corresponding author at: Physical Therapy Program, Utica College, New York.
back pain, and promoting sleep quality and spinal alignment. The
Tel.: +1 315 792 3853; fax: +1 315 7923248. level of evidence behind those trials was determined so that clini-
E-mail address: aradwan@utica.edu (A. Radwan). cians could have a better insight on the kind of mattress that they

http://dx.doi.org/10.1016/j.sleh.2015.08.001
2352-7218/© 2015 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.

Please cite this article as: Radwan A, et al, Effect of different mattress designs on promoting sleep quality, pain reduction, and spinal alignment
in adults with or without back pain; systematic review of control..., Sleep Health (2015), http://dx.doi.org/10.1016/j.sleh.2015.08.001
2 A. Radwan et al. / Sleep Health xxx (2015) xxx–xxx

Table 1
Summary of articles related to effects of different types and designs of mattresses on pain reduction.

Author PEDro Study design Participant Present Interventions Outcome Conclusion

(year) scale characteristics condition

Kovacs 10 Randomized, Number: ≥3-mo 155 patients allocated to Subjective: Patients who used the medium-
et al8 blinded, 313 chronic back medium-firm mattresses Self-reported pain intensity firm mattresses were more likely
controlled trial participants pain while 158 patients allocated to firm was measured daily while to have improvements in degree
Male lying in bed or mattresses lying in bed and 30 min after of disability than patients who
(n = 84) on rising. The study duration was 90 d. rising through the use of the used the firm mattresses.
Female VAS. Pain reduction was not
(n = 229) Degree of disability was statistically significant between
Age: measured using the Roland groups while lying in bed or
Median age: Morris questionnaire at upon rising.
44.55 y baseline and after 90 d. Patients with chronic back pain
will benefit more from a
medium-firm mattress than a
firm mattress.
McCall 8 Randomized Number: Asymptomatic Compared use of conventional Subjective: No significant statistical
et al9 controlled trial 12 (6 married mattress and 7-zone pressure- VAS for pain and sleep diaries differences between the 2
couples) relief mattress for 2 wk each Objective: mattresses in regard to any of
participants after a 2-wk baseline period. Actigraphy and pressure the outcome measures;
Age: mapping however, the pressure-relief
Range: 21-55 y mattress reduced the number
of high-pressure points.
Bergholdt 7 Randomized Number: SymptomaticCompared 3 different mattress Subjective: When compared with the hard
et al10 single-blinded 160 types: water bed (Akva), body- Danish COBRA questionnaire, mattress, the water bed and
clinical trial participants conforming foam mattress back pain, ADLs. foam mattresses had a more
Age: (Tempur), and hard mattress positive influence on back pain
Range: 18- (innovation Futon) for 1-mo and ADL performance.
60 y trial period; mattresses were
randomly assigned.
Jacobson 5 Controlled trial Number: Symptomatic Compared subject subjects’ Subjective: Participants showed significant
et al4 22 own bed for 28 d with VAS for back pain, back improvement in back pain,
participants prescribed sleep surface for stiffness, shoulder pain, and back stiffness, shoulder pain,
Age: another 28 d; prescribed sleep sleep quality. and sleep quality.
Range: 25-75 y surface based on subjects’
height and weight.
Jacobson 5 Controlled trial Number: Asymptomatic New, medium-firm bedding Subjective: Medium-firm bedding system
et al3 59 patients system. Subjects slept in their Two questionnaires. One will provide improved sleep
Male homes for 28 d on their own related to sleep habit and quality, comfort, and efficiency.
(n = 29) mattress, then for another 28 d another contained 32 items Significant improvements in
Female on the medium-firm mattress. related to behaviors sleep quality and comfort for
(n = 30) Total length of test was 56 d. manifested by anxiety, high- and low-baseline groups.
Age: restlessness, and stress. VAS
Mean age: used to assess 5 dependent
45.14 y variables: low back
discomfort, spine stiffness,
sleep quality, sleep comfort,
and sleep efficiency (time in
bed with time spent asleep).
Jacobson 5 Nonrandomized Number: Asymptomatic Phase I: Subjects slept on own Subjective: Reduction of pain and stiffness
et al5 controlled trial 59 subjects mattress for 28 consecutive Sleep promotion was and improvement of sleep
Male days. measured through comfort and quality became
(n = 29) Phase II: Subjects slept on VAS was used for sleep more prominent over time.
Female generic (unlabeled) mattress quality, comfort, and Cheaper bed systems, when
(n = 30) (medium-firm) for 28 efficiency. compared with the medium-/
Age: consecutive days. Pain reduction was measured high-priced bed systems, were
Mean age: Patients used VAS to record through the use of the VAS to significantly uncomfortable
45.14 y perception of 6 categories: measure low back pain, and promoted higher reports
(1) low back pain; shoulder pain, and spine of low back pain.
(2) shoulder pain; (3) spine stiffness. Medium to firm beds were
stiffness; (4) sleep quality; more comfortable than soft
(5) sleep comfort; and bedding systems.
(6) sleep efficiency. New bedding systems can
Five to six months follow-up. significantly improve sleep
variables. Thus, timely
replacement of old bedding
systems can significantly
improve sleep quality.
Jacobson 5 Controlled trial Number: Asymptomatic Comparing subjects’ own bed Subjective: Medium-firm mattress
et al11 59 with the introduction of VAS for sleep quality and low reduced back pain and
participants medium-firm mattress; 28-d back pain, 32-item stress improved sleep quality
Male evaluation period for each questionnaire. compared with subjects’ own
(n = 29) mattress. mattresses.
Female
(n = 30)

Please cite this article as: Radwan A, et al, Effect of different mattress designs on promoting sleep quality, pain reduction, and spinal alignment
in adults with or without back pain; systematic review of control..., Sleep Health (2015), http://dx.doi.org/10.1016/j.sleh.2015.08.001
 A. Radwan et al. / Sleep Health xxx (2015) xxx–xxx 3

Table 1 (continued)

Author PEDro Study design Participant Present Interventions Outcome Conclusion

(year) scale characteristics condition

Age:
Mean age:
45.14 y
Jacobson 5 Controlled trial Number: Symptomatic Compared subjects’ own Subjective: Significant decrease in back
et al2 27 mattresses for 3 wk with VAS for back pain, back pain, back stiffness, and
participants prescribed sleep surface for stiffness, shoulder pain, sleep shoulder pain, as well as an
Male 12 wk; subjects prescribed quality, and comfort upon increase in sleep quality and
(n = 13) sleep surface based on waking. comfort with the prescribed
Female dominant sleep position. sleep surface.
(n = 14)
Age:
Mean age:
44.8 y
Monsein 5 A-B-A design Number: Symptomatic, Adjustable airbed mattress; Subjective: Most patients with chronic
et al12 90 participants chronic back firmness control ranged from 0 Pain (VAS) and sleep on VAS nonspecific back pain will have
pain to 100. Length of test was 43 d. collected daily. SF-36 health improved sleep quality and
Day 1 was on own bed to status survey and the Epworth less pain on the adjustable
establish baseline. Days 2-29 Daytime Sleepiness scale on airbed.
were spent sleeping on airbed, days 0, 28, and 42. Followed
and days 29-43 were spent by a final interview.
sleeping on own mattress.
Price 5 Pilot study Number: Chronic pain This study was a 4-wk Subjective: There are statistically
et al13 19 participants plus sleep prospective A-B design in a Self-reported changes in sleep significant improvements in
Age: problems community setting. quantity and frequency of sleep and pain after 4 wk with
Mean age: 61 Participants completed pain sleep disturbance through the the use of a new (low-pressure
(SD ±14.24) VAS questionnaire at baseline use of a VAS (0-10). inflatable) overlay mattress.
Age range: and at weekly intervals Self-reported changes in pain
29-87 y concerning: (1) usual length of and use of analgesia.
sleep; (2) frequency of
waking; (3) length of time
awake; (4) cause of waking.
A low-pressure inflatable
mattress overlay (air rotation
overlay) was used in this study.

should recommend to their patients to reduce patients’ complaints to the PEDro scale to determine the methodological quality of
and to promote their sleep quality. reviewed articles and to increase the reliability of the systematic
review.14
Methodology
Results and discussion
This study aimed to answer the question of which mattress is the
best in regard to decreasing back pain and promoting spinal align- Twenty-four articles qualified to be included in this systematic re-
ment and sleep quality through performing a systematic review of view. The articles are summarized in Tables 1-3. The articles were re-
controlled trials. The inclusion criteria for our research include stud- lated to effect of different mattress designs on reducing back pain,
ies that were conducted between the years of 2000 and 2014, con- promoting sleep quality, and promoting spinal alignment, respective-
trolled trials, peer reviewed, performed on adults (18+ years), and ly. The articles included in this systematic review and the aforemen-
published in the English language. The article search was conducted tioned table will be discussed in the following order: effect of
using a combination of the following key words: Mattress and Ergo- mattresses on pain reduction, sleep comfort, and spinal alignment.
nomics, Mattress and Pain, Mattress and Spine, Mattress and Alignment.
Several databases were searched including CINAHL, Medline,
Medline Complete, ScienceDirect, CochraneCollaboration, Psychinfo, Mattress and pain reduction
EMBASE, and PEDro. The researchers then conducted a gray literature
search within the following databases: DARE, Proquest, and Google Based on the articles regarding pain reduction, the results provid-
Scholar. The search was completed through searching within individ- ed 3 general outcomes. There were 3 types of mattresses that provid-
ual ergonomics journals (Applied Ergonomics, Human Factors, Ergo- ed the most pain reduction for participants. Jacobson et al 3,5,11 and
nomics, and Industrial Ergonomics). After the relevant articles had Kovacs et al 8 correlated the use of a medium-firm bedding system
been located, the researchers then performed a snowballing tech- (based on subjective judgment of firmness) with a decrease in pain.
nique within each article’s reference list to expand our search for ap- Price et al13 and Monsein et al12 advocated for the use of an air mat-
propriate articles. tress overlay system in regard to decreasing pain. Lastly, Monsein
The initial search resulted in 65 articles related to mattresses and et al12 and Jacobson et al2 provided outcomes that associated a pre-
their effect on back pain, spinal alignment, and quality of sleep. Each scribed individualized bedding system to a reduction in pain. The
article was critically analyzed by 2 independent reviewers to deter- clinical studies provided by Sleep Number may support the idea of
mine its inclusion worthiness and its methodological quality. In a customized mattress to reduce pain; however, they did not meet
case of discrepancy between reviewers’ ratings, a third reviewer in- the inclusion standards of being controlled trials to be included in
tervened to clear the dispute. Reviewers scored each article according this systematic review. 15

Please cite this article as: Radwan A, et al, Effect of different mattress designs on promoting sleep quality, pain reduction, and spinal alignment
in adults with or without back pain; systematic review of control..., Sleep Health (2015), http://dx.doi.org/10.1016/j.sleh.2015.08.001
4 A. Radwan et al. / Sleep Health xxx (2015) xxx–xxx

Table 2
Summary of articles related to effects of different types and designs of mattresses on promoting sleep quality.

Author (year) PEDro Study design Participant Present Interventions Outcome Conclusion
scale characteristics condition

Bader & Engdal 6 Randomized Number: Asymptomatic Comparing soft and firm Objective: No significant difference in
(2000) controlled trial 10 participants mattress (with a soft Polysomngraphy data, sleep quality between
Age: mattress top used during movement durations, time mattress types. No one
Range: 30-54 y entire test); 3 consecutive in bed, total sleep time, global mattress design for
nights on own mattress sleep latency, population. An adequate
followed by 5 consecutive Subjective: mattress should be soft
nights on each test Following each night, enough to avoid excess
mattress. subjects answered compression of joints to
questions regarding levels prevent compression of
of fatigue, sleepiness, and neurovascular system.
any discomfort or pain. No
standardized subjective
outcome measure was
used.

Lahm and 6 Nonrandomized Number: Asymptomatic Stickers marked (C7-T12) Subjective: Change in mattress
Iaizzo16 controlled trial 23 participants spinous processes. Participants were asked to pressure had little
Male (n = 15) Adjustable air pressure give relative subjective physiologic significance,
Female (n = 7) bladder (low, mid, high). comfort pertaining to each despite the significant
Age: Participants remained lying bed pressure. changes in spinal
Range: 20-51 y for 30 min. Digital image One subset of 8 participants alignment.
Mean age: 25.2 was taken at 20-25 min. used a scale to rank each of Subjects reported higher
(SD ±8.7 y) Participants were able to the bed pressures. comfort with higher
walk for 5 min in between A second subset of 11 inflation measures.
pressure. Objectively, EMG, participants was asked to
heart rate, and blood rate on a scale of 1-10 (1
pressure were measured. being the least and 10
Subjectively, patient being the most
comfort was assessed. comfortable).
Objective:
EMG, heart rate, and blood
pressure.

López-Torres 6 Nonrandomized Number: Asymptomatic Four mattresses were used Subjective: As hardness increases (area
et al17 controlled trial 75 participants in this study: (1) spring Self-reported comparison under the load/deflection
Age: coil; (2) latex; between mattresses with 4 decreases), the perception
19 younger than (3) polyurethane; and possible answers: much of firmness increases.
35 y (4) 2 layers of foam. more, more, less, much less. As pressure/hardness
56 older than 65 y Patients placed their hands increases, subjective
and buttocks, lay supine, and comfort increases.
lay side-lying for 1 min. Increase in pressure/
Patients reported their level hardness is directly
of comfort subjectively with positively correlated with
2 groups of questions: ease of rolling.
(1) firmness perceived Ease of rolling is correlated
(hands, buttocks, supine, side with comfort.
lying); and (2) bed mobility:
(rolling over, getting up).

Raymann et al18 6 Experimental Number: Asymptomatic, Proximal and distal skin Subjective: Proximal warming
24 participants patients with temperature manipulation Sleep quality according to improved deep sleep, and
8 young adults insomnia via thermosuit between Pittsburgh Sleep Quality distal warming improved
8 elderly 12:00 and 6:00 AM. Cycling Index. REM.
asymptomatic between 31.7°C±.1°C in Objective:
adults "cool" and 34.5°C±.1°C in Stages of sleep: S1, S2, slow
8 elderly "warm." Total length of test wave sleep (SWS), and rapid
symptomatic was 4 d. Day 1 was spent eye movement (REM), as
adults sleeping at home. Day 2 well as occurrence of
Age: was spent sleeping in the wakefulness (WAKE).
Young adults: laboratory. Day 3 was spent
average age sleeping at home. Day 4
27.0 y; was spent sleeping in the
asymptomatic: laboratory. Subjects wore
average age the thermal suit on days 2
65.8 y; and 4.
symptomatic
adults: average
age 59.1 y

Please cite this article as: Radwan A, et al, Effect of different mattress designs on promoting sleep quality, pain reduction, and spinal alignment
in adults with or without back pain; systematic review of control..., Sleep Health (2015), http://dx.doi.org/10.1016/j.sleh.2015.08.001
 A. Radwan et al. / Sleep Health xxx (2015) xxx–xxx 5

Table 2 (continued)

Author (year) PEDro Study design Participant Present Interventions Outcome Conclusion
scale characteristics condition

Tonetti et al1 6 Actigraphic Number: Asymptomatic 6-wk trial with baseline Subjective: Sleep quality improved
study 28 participants and 2 experimental weeks Mini Sleep Questionnaire with Myoform mattress but
Male (n = 14) using spring and Myform and Hassles Scale. was not statistically
Female mattress. Baseline data Objective: significant.
(n = 14) were obtained during 1st Time in bed (TIB), sleep
Age: week. Then the following onset latency (SOL), total
Range: 30-71 y 2 wk were spent sleeping sleep time (TST), nocturnal
Mean age: on the spring mattress. awakenings lasting more
41.75 y Subjects returned home than 5 min (NA N 5), mean
during the 4th week to motor activity (MA), sleep
reestablish baseline on own efficiency (SE, %), and wake
mattress. Then weeks 5 and after sleep onset (WASO).
6 were spent sleeping on
the Myform mattress.

Tonetti et al1 6 Randomized Number: Asymptomatic Compared latex and spring Subjective: Results showed that both
controlled trial 28 participants mattresses for 1 wk after Mini Sleep Questionnaire, mattresses showed
Age: 3 wk of baseline and Profile of Mood State. significant improvement in
Range: 26-57 y adaptation periods. Objective: objective sleep quality
Actigraphic data. (when compared with
baseline); however, there
were no significant
differences between the 2
mattresses.

McCall et al9 6 Controlled trial Number: Asymptomatic Compared active-control Subjective: Active control system with
11 participants “smart” bedding system: Karolinska Sleepiness Scale, dynamic configuration
Age: comparing standard Profile of Mood State, and resulted in increased sleep
Range:20-28 configuration for 1 night sleep diary. quality. Participants
and dynamic configuration Objective: perceived less awakenings
for 1 night. Polysomnographic data. and awakenings were
shorter with the active
control system with
dynamic configuration.

Verhaert et al19 6 Nonrandomized Number: Asymptomatic This study was a 3-d Subjective: The effect of bed design on
controlled trial 17 participants experiment that compared Self-reported sleep cannot be fully
Male (n = 9) 2 conditions: (1) reference questionnaires were used assessed by just comparing
Female (n = 8) condition with a including (1) VAS (0-20), the 2 sleep systems.
Age: personalized and (2) Karolinska Sleepiness A sagging sleep system has
Mean age: 24.3 (2) induction condition Scale, (3) Cox’s Stress/ a negative effect on sleep
(SD ±7.1 y) with a sagging mattress. Arousal, (4) Adjective quality for individuals who
Check List, (5) the fatigue spend most time in a lateral
scale of Profile of Mood and prone sleep position.
States. Individuals who slept in the
Objective: lateral or prone sleeping
(1) Polysonography, position also spent
(2) video recording. significantly less time in
REM when compared with
the reference condition.

Jacobson et al4 5 Controlled trial Number: Symptomatic Compared subjects’ own Subjective: Participants showed
22 participants bed for 28 d to prescribed VAS for back pain, back significant improvement in
Age: sleep surface for another stiffness, shoulder pain, and back pain, back stiffness,
Range: 25-75 y 28 d; prescribed sleep sleep quality. shoulder pain, and sleep
surface based on subjects’ quality.
height and weight.

Jacobson et al3 5 Controlled trial Number: Asymptomatic New, medium-firm Subjective: Medium-firm bedding
59 patients bedding system. Subjects Two questionnaires. One system will provide
Male (n = 29) slept in their homes for related to sleep habit and improved sleep quality,
Female 28 d on their own mattress, another contained 32 items comfort, and efficiency.
(n = 30) then for another 28 d on related to behaviors Significant improvements
Age: the medium-firm mattress. manifested by anxiety, in sleep quality and
Mean age: Total length of test was restlessness, and stress. comfort for high- and low-
45.14 y 56 d. VAS used to assess 5 baseline groups.
dependent variables: low
back discomfort, spine
stiffness, sleep quality,
sleep comfort, and sleep
efficiency (time in bed with
time spent asleep).

(continued on next page)

Please cite this article as: Radwan A, et al, Effect of different mattress designs on promoting sleep quality, pain reduction, and spinal alignment
in adults with or without back pain; systematic review of control..., Sleep Health (2015), http://dx.doi.org/10.1016/j.sleh.2015.08.001
6 A. Radwan et al. / Sleep Health xxx (2015) xxx–xxx

Table 2 (continued)

Author (year) PEDro Study design Participant Present Interventions Outcome Conclusion
scale characteristics condition

Jacobson et al5 5 Nonrandomized Number: Asymptomatic Phase I: Subjects slept on Subjective: Reduction of pain and
controlled trial 59 subjects own mattress for 28 Sleep promotion was stiffness and improvement
Male (n = 29) consecutive days. measured through of sleep comfort and
Female Phase II: Subjects slept on VAS was utilized for sleep quality became more
(n = 30) generic (unlabeled) quality, comfort and prominent over time.
Age: mattress (medium-firm) efficiency. Cheaper bed systems, when
Mean age: for 28 consecutive days Pain reduction was compared with the
45.14 y Patients used VAS to record measured through the use medium-/high-priced bed
perception of six of the VAS to measure low systems, were significantly
categories: (1) low back back pain, shoulder pain, uncomfortable and
pain; (2) shoulder pain; and spine stiffness. promoted higher reports of
(3) spine stiffness; low back pain.
(4) sleep quality; (5) sleep Medium to firm beds were
comfort; and (6) sleep more comfortable than soft
efficiency. bedding systems.
5- to 6-mo follow-up. New bedding systems can
significantly improve sleep
variables. Thus, timely
replacement of old bedding
systems can significantly
improve sleep quality.

Jacobson et al11 5 Controlled trial Number: Asymptomatic Comparing subjects own Subjective: Medium-firm mattress
59 participants bed to introduction of VAS for sleep quality and reduced back pain and
Male (n = 29) medium-firm mattress; low back pain, 32 item improved sleep quality
Female 28 day evaluation period stress questionnaire. compared with subjects
(n = 30) for each mattress. own mattress.
Age:
Mean age
45.14 y

Jacobson et al2 5 Controlled Trial Number: Symptomatic Compared subjects’ own Subjective: Significant decrease in back
27 participants mattress for 3 wk to VAS for back pain, back pain, back stiffness, and
Male (n = 13) prescribed sleep surface for stiffness, shoulder pain, shoulder pain as well as an
Female 12 wk; subjects prescribed sleep quality, and comfort increase in sleep quality
(n = 14) sleep surface based on upon waking. and comfort with the
Age: dominant sleep position prescribed sleep surface
Mean age: 44.8

Monsein et al12 5 A-B-A design Number: Symptomatic, Adjustable airbed mattress; Subjective: Most patients with chronic
90 participants chronic back firmness control ranged Pain (VAS) and sleep on nonspecific back pain will
pain. from 0 to 100. Length of VAS collected daily. SF-36 have improved sleep
test was 43 d long. Day 1 health status survey and quality and less pain on the
was on own bed to the Epworth Daytime adjustable airbed.
establish baseline. Days 2- Sleepiness scale on days 0,
29 were spent sleeping on 28, and 42. Followed by a
airbed, and days 29-43 final interview.
were spent sleeping on
own mattress.

Park et al20 5 Multicenter Number: Asymptomatic Six materials: 3 kinds of Subjective: Most favored mattress by
controlled trial 18 participants cotton, felt, sponge, and Six evaluation charts using the subjective ratings was
Male (n = 9) elastic cotton. Three 7-point scales divided into the mattress in which the
Female (n = 9) springs: 3 pitch, 4 pitch, 5 2 segments asking physical spinal curvature in lying
Age: pitch. Subjects wore features and level of was most similar to that in
Range: 25-50 y spandex. Subjects graded satisfaction. standing.
comfort by filling out 6 Objective: Average pressure at the
evaluation charts that used 3D measurement of spinal shoulder was higher in
a 7-point scale divided into curvature in standing softer beds.
2 sections concerning Measure points were at C7, The study found that
physical features and T1, T3, T7, T9, T11, L2, L5/ firmness had to be
satisfaction with the S1. extended to increase in
features. Trial took Pressure at the hip and patient comfort.
180 min, with each shoulder measured with
mattress being tested for a the pressure sensor matrix.
period of 10 min.

Price et al13 5 Pilot study Number: Chronic pain This study was a 4-wk Subjective: There are statistically
19 participants plus sleep prospective A-B design in a Self-reported changes in significant improvements
Age: problems community setting. sleep quantity and in sleep and pain after 4 wk
Mean age: 61 y Participants completed frequency of sleep with the use of a new (low-
(SD ±14.24) pain VAS questionnaire at disturbance through the pressure inflatable) overlay
Age range: baseline and at weekly use of a VAS (0-10). mattress.
29-87 y intervals concerning Self-reported changes in

Please cite this article as: Radwan A, et al, Effect of different mattress designs on promoting sleep quality, pain reduction, and spinal alignment
in adults with or without back pain; systematic review of control..., Sleep Health (2015), http://dx.doi.org/10.1016/j.sleh.2015.08.001
 A. Radwan et al. / Sleep Health xxx (2015) xxx–xxx 7

Table 2 (continued)

Author (year) PEDro Study design Participant Present Interventions Outcome Conclusion
scale characteristics condition

(1) usual length of sleep; pain and use of analgesia.

(2) frequency of waking;
(3) length of time awake;
and (4) cause of waking.
A low-pressure inflatable
mattress overlay (air
rotation overlay) was used
in this study.

Shen et al21 5 Randomized Number: Asymptomatic Compared 18 different Objective: Subjects who slept on
control trial 8 participants commercial spring Polysonography mattresses with poor
Age: mattresses (5 different (electrocardiogram, stability have lower
Range: 20-32 y spring cores, 14 different electrooculogram, percentages of deep sleep
top comfort combination electroencephalogram, EMG), and sleep efficiency,
layers). All subjects used actigraphy (sleep/wake whereas wake after sleep
thin cotton-filled mattress behavior), bodily onset was higher.
top. Each subject recorded movements. Mattresses with poor
at least 4 consecutive Subjective: stability lead to more
nights on each of the 18 Nonstandardized movements and did not
mattresses. questionnaire reading days’ favor sleep.
events and level of fatigue An appropriate mattress is
of body parts before sleep. one that is composed of
Also, questions regarding proper bedding materials,
external disturbances, mattress core, and
quality of sleep level of structure that are
fatigue, sleepiness, individualized to each
discomfort, and pain after person.
sleep. Article did not
mention if a VAS was used
to measure pain.

Lee et al (2006)22 4 Randomized Number: Asymptomatic Comparing comfortable Subjective: Comfortable mattresses are
control trial 16 participants and uncomfortable Personal recordings about necessary to support the
Age: mattress defined by sleep quality. spine and minimize
Range: 20-30 maintenance spinal Objective: unnecessary body
curvature and pressure Polysonography data, skin movements, facilitate
distribution in standing and temperature. higher sleep quality and
lying; 6 consecutive nights maintain higher body
(3-4 for adaptation, 2-3 for temperature.
data extraction) on each
mattress.

With regard to pain reduction, Jacobson et al 2 conducted a con- With regard to sleep quality and comfort, Jacobson et al 5 com-
trolled trial that explored the effect of individually prescribed pared personal and new bedding systems using subjective ratings
sleeping surfaces on back pain and sleep quality, with participants through use of a VAS. Phase 1 of the study was a pretest in which
serving as their own control. In the “pretest” portion of this study, the subjects slept in their personal beds and rated the VAS upon wak-
the individuals all slept on their own beds for 3 weeks while rating ing for 28 consecutive days. Phase 2, posttest, began when the generic
back and shoulder discomfort/pain as well as sleep quality and com- bedding system was delivered to the participants’ homes, with the
fort via visual analog scales (VASs). The subjects were then pre- subjects completing the same evaluations for 28 consecutive days.
scribed a mattress based on what they reported to be their In addition, 5 to 6 months after the initial experimental phase, sub-
prominent sleeping position. The subjects then continued to rate jects were also asked to complete a satisfaction questionnaire on
pain/discomfort and sleep quality and comfort on a VAS daily for an- the new bedding system to affect the sustainability of positive effects
other 12 weeks. The results showed significant decrease in back pain, of the new bedding system. This study found no significant 4-week
back stiffness, and shoulder pain as well as an increase in sleep qual- post differences among any of the grouped dependent variables,
ity and comfort with use of the prescribed sleep system.2 which indicates that, for the pretest (28 days in subjects’ personal
Similarly, Jacobson et al11 performed a controlled trial that assessed beds), the subjects experienced consistent pain, sleeping comfort,
the effects of a medium-firm bedding system. Visual analog scales sleeping quality, and sleeping efficiency. Therefore, it suggests that
were used to assess the subject’s perception of sleep quality as well new bedding system of medium firmness and of quality construction
as low back pain and were to be filled out each morning upon rising. provided improved comfort for those with minor pain and stiffness.
The baseline period lasted 28 days before the experimental phase Assessing sleep quality, Jacobson et al 3 conducted a study com-
began. During this phase, the subjects were assigned a bed that paring a commercial spring mattress to a medium-firm mattress.
contained a medium-firm sleep surface, foam-encased Bonnell spring Subjects compared their own mattress with a medium-firm mattress
unit, densified fiber pad, super-soft foam, damask cover, semiflex foun- used for 28 consecutive days using sleep questionnaires and a VAS.
dation, and slick fiber. At the end of the 28-day experimental phase, Outcomes revealed that there were significant differences between
the results showed that the medium-firm bedding system reduced all measurements for high–pain baseline groups. In addition, signifi-
back pain by about 48% and improved sleep quality by about 55%.11 cant improvements were seen in spine stiffness, sleep efficiency,

Please cite this article as: Radwan A, et al, Effect of different mattress designs on promoting sleep quality, pain reduction, and spinal alignment
in adults with or without back pain; systematic review of control..., Sleep Health (2015), http://dx.doi.org/10.1016/j.sleh.2015.08.001
8 A. Radwan et al. / Sleep Health xxx (2015) xxx–xxx

Table 3
Summary of articles related to effects of different types and designs of mattresses on promoting spinal alignment.

Author PEDro Study design Participant Present Interventions Outcome Conclusion

(year) scale characteristics condition

DeVocht 8 Controlled trial Number: Asymptomatic Compared 4 “top of the line” Objective: The pelvic region had higher
et al6 18 queen-sized mattresses in Postural distortion was pressure values when
participants side lying (for postural measured by marking the compared with the thoracic
All male distortion) and supine (for spinous processes and using region. The least amount of
Age: pressure distribution). The a camera to capture any pressure was seen in mattress
Not stated mattresses were labeled as distortion present. A (Perfect Contour
follows: mattress A, Perfect Pressure distribution was Extraordinare Dorchester by
Contour Extraordinaire measured by having the King Koil), and the most
Dorchester by King Koil; participants lie in supine pressure was seen in mattress
mattress B, Beautyrest Calibri with two XSensor model D (Perfect Sleeper Southdale
Firm by Simmons; mattress C, X236 pressure-sensitive pads by Serta). Mattress D also
Posturepedic Afton Plush by on top of the mattress. demonstrated the least spinal
Sealy; mattress D, Perfect distortion.
Sleeper Southdale by Serta.
Leilnahari 5 Controlled trial Number: Asymptomatic Comparing soft (polyurethane Objective: Neither a soft nor firm
et al23 25 participants foam), firm, and custom- Spine alignment was mattress is sufficient to
All male made mattress. Markers were examined in side-lying support spine alignment. Too
placed on spinous process of position. The angle of the
soft of a mattress results in
C7-L2 and L5. The length of vertebrae (π-P8) was cervical spine being in a
the study took 1 d; however, captured from 2 digital higher position than the
the time spent in the side- cameras. The digital cameras
pelvis, which can lead to
lying position was not stated. used were model DCR- malalignment.
Too firm of a mattress will not
TRV356E, Sony Corporation,
Tokyo, Japan. Then 3D skele-
allow shoulders to sag into
tal models were built using
the mattress, which leads to
BRG.LifeMOD. improper support of neck and
back. A customized inflatable
model is more conducive to
maintain spinal alignment.
Norman 5 Quasiexperimental Number: Asymptomatic Compared 3 different surfaces Objective: Use of inflated lumbar
et al24 10 participants (no mattress, 8 cm of foam, Contact pressure in lumbar, cushion allowed for more
Age: 14-cm latex mattress of pelvic, and thoracic regions homogenous distribution of
Range: 22-31 y medium density) with and while lying in supine for 30 s. pressure and decreased
without lumbar cushion for a pressure in the thoracic and
total of 6 experimental pelvic regions. Maintained
conditions. lumbar lordosis, allowing for
more natural spine curvature
in supine lying.
Park 5 Multicenter Number: Asymptomatic Six materials: 3 kinds of Subjective: Most favored mattress by the
et al20 controlled trial 18 participants cotton, felt, sponge, and Six evaluation charts using subjective ratings was the
Male (n = 9) elastic cotton. Three springs: 3 7-point scales divided into 2 mattress in which the spinal
Female pitch, 4 pitch, 5 pitch. Subjects segments asking physical curvature in lying was most
(n = 9) wore spandex. Subjects features and level of similar to that in standing.
Age: graded comfort by filling out 6 satisfaction. Average pressure at the
Range: 25-50 y evaluation charts that used a Objective: shoulder was higher in softer
7-point scale divided into 2 3D measurement of spinal beds.
sections concerning physical curvature in standing The study found that firmness
features and satisfaction with Measure points were at C7, had to be extended to
the features. Trial took T1, T3, T7, T9, T11, L2, L5/S1. increase in patient comfort.
180 min, with each mattress Pressure at the hip and
being tested for a period of shoulder was measured with
10 min. the pressure sensor matrix.

and sleep quality for high- and low-baseline groups. Multiple the participants at baseline and at 90 days of the clinical study. Partic-
regressions showed that body weight, height, and bed age were ipants were asked to rate their own low back pain level every morn-
significant predictors for back pain, stiffness, and sleep quality. Body ing both while lying in bed and upon rising (within at least 30
mass index appeared to play a role in sleep quality, as the average minutes). At baseline and 90 days, participants also completed the
body mass index of the participants of this study was found to Roland Morris disability questionnaire. The results concluded that al-
be overweight, resulting in poorer sleep quality. In conclusion, signif- though the results showed improvements for both mattresses, the
icant improvements were found in all measured variables for medium-firm mattress (rated 5-6 on a 10-point scale of firmness)
the medium-firm mattress; however, the authors suggested showed a higher proportion of improvement for the participants.
that implementing an exercise regimen to decrease weight and im- Therefore, Kovacs et al8 suggest medium-firm mattresses for patients
prove overall health might be as beneficial as sleeping on a medium- with chronic nonspecific low back pain.
firm mattress.3 Evaluating the effect of a prescribed bedding system, Jacobson
With regard to symptomatic patients, Kovacs et al 8 evaluated the et al4 used a quasiexperimental pretest/posttest design, which used
effects of various levels of firmness on participants. The firmness symptomatic subjects as their own control. The subjects had docu-
levels of the 2 groups of mattresses were rated using the European mented disturbed sleep, shoulder pain, low back pain, or spine stiff-
Committee for Standardizaiton Scale. Research assistants assessed ness of a chronic nature. The subjects used VAS to rate back pain,

Please cite this article as: Radwan A, et al, Effect of different mattress designs on promoting sleep quality, pain reduction, and spinal alignment
in adults with or without back pain; systematic review of control..., Sleep Health (2015), http://dx.doi.org/10.1016/j.sleh.2015.08.001
 A. Radwan et al. / Sleep Health xxx (2015) xxx–xxx 9

back stiffness, shoulder pain, and quality of sleep upon waking for 28 comfort combination layers. Subjective questions were also answered
days while sleeping on their own beds. Then, following a before bedtime and the following morning.21
predetermined system that used the subjects’ height and weight, a There was no significant correlation between mattress firmness
bedding system was prescribed for them to use for another 28 days and sleep quality 21; however, the authors reported that subjects
while continuing to rate each category upon waking. The results slept deeply and efficiently on softer mattresses varieties and con-
showed a significant improvement in shoulder pain (60.83%), back cluded that optimal mattress should be individualized (self-
pain (57.21%), and back stiffness (59.12%) with the use of the pre- adjusted) to accommodate individual differences and facilitate
scribed bedding system. deep sleep.
Assessing symptomatic participants, Monsein et al 12 examined In attempts to investigate mattresses, Tonetti et al1 compared an
the effects of pain reduction and sleep quality with an innerspring old personal mattress to 2 new mattresses including a Myoform mat-
mattress and a mattress with an added adjustable airbed mattress tress and one with standard technology. Participants slept on each
top using an A-B-A design. The participants contributed baseline mattress for a 1-week time trial period, with an adaptation week in
data from their recent experience on their own mattress (A). In the between each mattress before recording to allow the participant to
second (B) segment, the airbed was installed for 28 days. After the adapt to the new bedding system. Subjects completed a Mini Sleep
airbed intervention, the patient's own bed was reinstalled, and the Questionnaire to subjectively rate sleep quality, along with a Hassles
patient outcomes were tracked for an additional 14 days. Subjective Scale to evaluate stress level. The results showed that subjects spent
measures included Short Form (SF)–36 health survey, Epworth Day- less time in bed when sleeping on the Myform mattress, yet had bet-
time Sleepiness Scale, and VAS. When sleeping on the airbed mat- ter sleep efficiency and shorter sleep onset latency.1 Perceived sleep
tress, subjects reported less pain and a higher level of sleep quality. quality or actigraphic sleep measures showed no significant differ-
The results demonstrated that individuals with chronic nonspecific ences between either of the mattresses.
back pain would have improved sleep on an adjustable airbed. Park et al20 aimed to identify a correlation between the character-
Similar results of pain reduction were obtained through using an istic of mattresses, anthropometric features, body pressure distribu-
air rotation overlay. Price et al13 conducted a study using an A-B de- tion, and spinal curvature to examine the overall relationship
sign. This study used an air rotation overlay (Repose; Frontier Thera- between the comfort and the features of a mattress. Six different
peutics Ltd, Blackwood, South Wales), which is a low-pressure mattress materials were used: 3 different kinds of cotton, felt, sponge,
inflatable mattress overlay. In the A-B design study, subjects were and elastic cotton. Three-dimensional measurements were per-
asked to provide data on their own mattress experience (A); then, formed to estimate the spinal curvature in supine and standing posi-
subjects were asked to record their experience after using the overlay tion. Pressure measurements were obtained using a sensor matrix at
mattress after 4 weeks (B) using sleep quality questionnaires and a the shoulder to hip distribution. For the subjects to subjectively rate
VAS. Researchers concluded that there were statistically significant mattress comfort, they were asked to grade each surface on a
improvements in sleep quality and pain reduction after the 4-week 7-point scale. Results of this study concluded that the most favored
duration on the overlay mattress. Furthermore, 1 month after com- mattress by the subjective ratings was the mattress in which the spi-
pleting the study, 17 patients had voluntarily continued to use the nal curvature in lying posture was similar to that in standing posture.
overlay mattress. Assessing sleep depth, Raymann et al 20 manipulated cutaneous
The evidence provided in this section supports the use of medium- body temperature through the use of a water-perfused thermosuit,
firm mattresses to promote pain reduction while sleeping. Most of the with proximal (trunk and limbs) and distal (hands and feet) skin
studies calculated the firmness of mattresses based on subjective eval- temperatures within a narrow range of 0.4°C. Slowly cycling temper-
uations, except Kovacs et al8 who used the European Committee Stan- atures were differentially manipulated by thermosuit water perfu-
dardization Scale of firmness of mattresses. Support systems of sion both distally and proximally 30 minutes into the experiment
mattresses were hardly mentioned in articles except in a few. 11 In until 6:00 AM. Raymann et al 18 demonstrated that sleep depth is af-
most cases, reduction in pain was subjectively determined by each fected by manipulation of skin temperature, distally and proximally,
participant’s own rating on functional scales. due to the fact that their study did not change core body temperature.
The findings suggest that mild proximal skin temperature warming
can be chosen to reduce early morning awakening and enhance
Mattress and sleep quality deeper sleep.
To differentiate between comfortable and uncomfortable mat-
According to this systematic review, medium firmness of bedding tresses, Hyunja and Park 26 studied the quantitative effects via
system is correlated with better sleep quality 3,5,11; mattresses in polysomnography and skin temperature. Comfort was evaluated in
which the spinal curvature in lying was similar to standing posture terms of the distribution of the body pressure on the mattress and
also produced favorable outcomes in terms of sleep quality.1,2,4,20,21,25 the difference in the spinal curvature between standing and lying. A
Similarly, using an adjustable bed based on individual preference pro- comfortable mattress was defined as one that maintained similar spi-
moted sleep quality.17,26 Finally, one study reported that subtle skin nal curvature in both standing and supine positions. An uncomfort-
warming can produce improved sleep quality by reducing early morn- able mattress was defined as one that did not maintain similar
ing wakening and enhancing deep sleep.18 spinal curvature in both positions. Subjects experienced an adapta-
Considering the relation between mattress design and sleep quali- tion period before the study and then completed a 2-night test in
ty, Shen et al21 investigated bedding materials and the structural prop- which the mattresses were randomly selected. Upon waking, subjects
erties of the bedding layer in spring mattresses. Data were collected on answered subjective questions about sleep, whereas electroencepha-
each subject for at least 4 consecutive nights on each of the 18 mat- lographic, electromyography (EMG), electrooculography, electrocar-
tresses. Polysomnographic data were collected from each individual diography, and skin temperatures were all obtained during the
including electroencephalograph to monitor neuroelectrical activity, study. Mattresses that were deemed comfortable in this study by par-
electrooculogram to monitor eye movements, electrocardiograph to ticipants happened to be the ones that resulted in higher skin tem-
determine sleep stages, and electromyography to monitor movement. perature and were firm enough to support the spine curvature and
The mattresses used in the study were commercial spring mattresses, minimize unnecessary body movements. These comfortable mat-
combined with 5 types of spring mattress cores and 14 kinds of top tresses did facilitate higher sleep quality.

Please cite this article as: Radwan A, et al, Effect of different mattress designs on promoting sleep quality, pain reduction, and spinal alignment
in adults with or without back pain; systematic review of control..., Sleep Health (2015), http://dx.doi.org/10.1016/j.sleh.2015.08.001
10 A. Radwan et al. / Sleep Health xxx (2015) xxx–xxx

Mattress and spinal alignment It was concluded that spinal alignment has an effect on sleep, with
significant improvements reported by the participants using the 8-
As it concerns spinal alignment, the included articles in the study zone adjustable sleep system.19
were all in favor of the mattress being individualized to fit the needs Expanding on the previous study, Verhaert et al 27 published an
of the patient. The spinal alignment in supine should be similar to abstract using an algorithm for control of spinal alignment during
that in standing, which was supported by Park et al.20 The standing sleep through the activation of bed characteristics according to
posture varies for each individual, leading to the notion that the mat- sleep posture. An active control bedding system including 8 comfort
tress should be custom made based on this posture, which is further zones was used through adjustable actuators that estimated spine
supported by Leilnahari et al23 and DeVocht et al.6 The Sleep Number shape by detecting mattress indentations based on body movement.
clinical trials also supported this outcome, as beds in which firmness The results from the abstract supported the previous study per-
could be controlled by the individual had minimal effects on formed by Verhaert et al19 that there was an improvement in spinal
distorting spinal alignment 15; however, they were not included in alignment with the use of an active control bedding system com-
this review because of the low quality index and because they did pared with sleeping on a bed without the active control system.
not meet the inclusion criteria.
Assessing spinal support in men, Leilnahari et al 23 tested soft,
firm, and custom-made mattress designs. Markers were mounted Conclusion
on the spinous processes of the vertebrae of the participants, and spi-
nal alignment was registered via an optical tracking method in the According to this systematic review, the following conclusions
lateral sleep position on the 3 mattress designs. Each subject lay in could be reached:
the lateral position twice on each of the soft and firm mattresses • Medium-firm mattresses are beneficial for individuals with
while images were captured. Outcomes of the study concluded that chronic nonspecific low back pain and were rated as more com-
if the mattress was too firm, the shoulders would not be able to fortable than soft bedding systems. Studies have shown that
“sag” into the mattress, thus not allowing proper support of the medium-firm mattresses improve sleep quality by 55% and de-
neck and back, leading to pain and joint stiffness. If the mattress crease back pain by 48% in patients with chronic low back pain.
was too soft, the pelvis would sag more into the mattress, resulting • When an individual has active control of bed properties (custom
in the cervical spine being higher than the pelvis, leading to inflation), there is an improvement in spinal alignment as well
malalignment. The outcome of the study concluded that the use of a as sleep quality. In addition, in both young and older adults,
custom-made (custom inflation) mattress would provide better spi- proximal warming enhanced sleep.
nal support for men during sleep in the lateral position. • Mild skin temperature manipulation can be chosen to reduce
To measure spinal distortion and maximal pressure points, early morning awakening and enhance deeper sleep; however,
DeVocht et al 6 compared 4 different mattresses. The mat- the reader should be cautious that this temperature conclusion
tresses used were as follows: a perfect contour extraordinaire is solely based on the findings of a single article that met the in-
Dorchester by King Koil, a Beautyrest Calibri Firm by Simmons, clusion criteria of this systematic review.
a Posturepedic Afton Plush by Sealy, and a Perfect Sleeper • Soft mattresses decrease excessive compressive forces on joints.
Southdale by Serta. To measure postural distortion, a research On the other hand, firm mattresses help maintain appropriate
assistant palpated the spinous processes, and patients were sleeping posture especially in side-lying position, as it prevents
instructed to lie in side-lying followed by supine position. the sagging of the pelvis. However, the clinical value of such
The results showed that, as expected, body type was directly findings has not been confirmed yet.
related to maximum pressure. The pelvic region had higher-
pressure values when compared with the thoracic region, cor-
relating to a greater maximum pressure in the pelvic region
Limitation
compared with the thoracic region. The least maximum pres-
sure was observed for the perfect contour extraordinaire Dor-
This review is limited by the lack of agreement between authors
chester by King Koil, whereas the Perfect Sleeper Southdale
about a universal system for measuring mattresses’ firmness as most
by Serta demonstrated the greatest maximal pressure. Overall,
of the included studies have adapted a subjective rating of firmness.
the Perfect Sleeper Southdale by Serta tended to demonstrate
Also, support systems of mattresses were rarely mentioned by original
the lowest spinal distortion, while also having the greatest
authors despite the roles that such supports could play in the overall
maximum pressure.
performance of mattresses and their long-lasting performance. Finally,
Included in the gray literature discussion, Verhaert et al 19 pub-
most of the data obtained in regard to reduction in pain or improve-
lished a dissertation focusing on the bedding system (ie, the combi-
ment in symptoms were based on subjective ratings of participants’
nation of mattress, bed support, and pillow) and its effect on the
outcomes rather than on objective measurements except in a few ar-
environmental factors a sleeping individual would possess. The aim
ticles that truly assessed electrophysiological activities while sleeping.
of the study was to aid in developing a dynamically controlled sleep
system that will adjust to an individual user and continue to provide
support through the night. First, researchers examined the effects of Future research
spinal alignment on sleep parameters, followed by observing motor
patterns during sleep. This process led to the development of an algo- Authors recommend researchers in this field to appropriately de-
rithm to detect body movements and sleep patterns based on inden- sign randomized controlled trials that measure the reduction in pain
tation marks made by the individual. The researchers then used a and improvement in sleep quality and spinal alignment using a variety
generic sleep model, representing a human body, to not disturb live of well measured firmness levels of mattresses, well-determined sup-
test subjects during sleep. Sleep model surfaces were developed port systems, and combination of subjective and objective outcome
using anthropometric measurements from the participants’ mea- measures to support the conclusions. This should be followed by longi-
surements. The researchers then compared the actively controlled tudinal studies to assess the long-term functionality and performance
system with a static bedding system using the original participants. of the mattresses of choice and their abilities to maintain comfort.

Please cite this article as: Radwan A, et al, Effect of different mattress designs on promoting sleep quality, pain reduction, and spinal alignment
in adults with or without back pain; systematic review of control..., Sleep Health (2015), http://dx.doi.org/10.1016/j.sleh.2015.08.001
 A. Radwan et al. / Sleep Health xxx (2015) xxx–xxx 11

Disclosure 14. Portney LG, Watkins MP. Foundations of clinical research: applications to practice.
3rd ed. Upper Saddle River, N.J.: Pearson/Prentice Hall; 2009
15. Articles, Research, & News. Retrieved November 6, 2014. From http://www.
There is no conflict of interest to report. sleepnumber.com/articles/articles-research.
16. Lahm R, Iaizzo PA. Physiologic responses during rest on a sleep system at varied
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Please cite this article as: Radwan A, et al, Effect of different mattress designs on promoting sleep quality, pain reduction, and spinal alignment
in adults with or without back pain; systematic review of control..., Sleep Health (2015), http://dx.doi.org/10.1016/j.sleh.2015.08.001