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Effect of prescribed sleep surfaces on back pain and sleep quality in patients diagnosed with low back and shoulder pain

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The purpose of this study was to assess sleep quality and comfort of participants diagnosed with low back pain and stiffness following sleep on individually prescribed mattresses based on dominant sleeping positions. Subjects consisted of 27 patients (females, n=14; males, n=13; age 44.8 yrs ± SD 14.6, weight 174 lb. ± SD 39.6, height 68.3 in. ± SD 3.7) referred by chiropractic physicians for the study. For the baseline (pretest) data subjects recorded back and shoulder discomfort, sleep quality and comfort by visual analog scales (VAS) for 21 days while sleeping in their own beds. Subsequently, participants' beds were replaced by medium-firm mattresses specifically layered with foam and latex based on the participants' reported prominent sleeping position and they again rated their sleep comfort and quality daily for the following 12 weeks. Analysis yielded significant differences between pre- and post means for all variables and for back pain, we found significant (p<0.01) differences between the first posttest mean and weeks 4 and weeks 8-12, thus indicating progressive improvement in both back pain and stiffness while sleeping on the new mattresses. Additionally, the number of days per week of experiencing poor sleep and physical discomfort decreased significantly. It was concluded that sleep surfaces are related to sleep discomfort and that is indeed possible to reduce pain and discomfort and to increase sleep quality in those with chronic back pain by replacing mattresses based on sleeping position.
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Effect of prescribed sleep surfaces on back pain and sleep quality in patients
diagnosed with low back and shoulder pain
Bert H. Jacobson
, Ali Boolani, Guy Dunklee, Angela Shepardson, Hom Acharya
204 Willard Hall, Oklahoma State University, Stillwater, OK 74078, USA
article info
Article history:
Received 24 September 2009
Accepted 15 May 2010
Sleep quality
The purpose of this study was to assess sleep quality and comfort of participants diagnosed with low
back pain and stiffness following sleep on individually prescribed mattresses based on dominant
sleeping positions. Subjects consisted of 27 patients (females, n¼14; males, n¼13; age 44.8 yrs SD
14.6, weight 174 lb. SD 39.6, height 68.3 in. SD 3.7) referred by chiropractic physicians for the study.
For the baseline (pretest) data subjects recorded back and shoulder discomfort, sleep quality and comfort
by visual analog scales (VAS) for 21 days while sleeping in their own beds. Subsequently, participants
beds were replaced by medium-rm mattresses specically layered with foam and latex based on the
participantsreported prominent sleeping position and they again rated their sleep comfort and quality
daily for the following 12 weeks. Analysis yielded signicant differences between pre- and post means
for all variables and for back pain, we found signicant (p<0.01) differences between the rst posttest
mean and weeks 4 and weeks 8e12, thus indicating progressive improvement in both back pain and
stiffness while sleeping on the new mattresses. Additionally, the number of days per week of experi-
encing poor sleep and physical discomfort decreased signicantly. It was concluded that sleep surfaces
are related to sleep discomfort and that is indeed possible to reduce pain and discomfort and to increase
sleep quality in those with chronic back pain by replacing mattresses based on sleeping position.
Ó2009 Published by Elsevier Ltd.
1. Introduction
Sleep is essential to physical, mental and emotional health. For
most adults, 7e8 h of sleep per night appears to be the ideal,
however, 75% of Americans have sleep problems during a typical
week (National Sleep Foundation, 2005). It has been estimated that
over 70 million people are currentlyaffected by sleep problems and
this number is expected to increase to over 100 million by 2050
(Reiter, 2005). Currently, the average adult gets less than seven
hours of sleep per night (National Sleep Foundation, 2005) and
such chronic lack of sleep (insomnia) affects quality of life, social
interaction and mood (Lee, 2005). Additionally, sleep deciency
results in loss of work production, increased sick days, greater
absenteeism, loss of productivity and higher injury rates (Chilcott
and Shapiro, 1996; Drake et al., 2004; Ohanyon and Lemoinie,
2004; Godet-Cayreet al., 2006; Hillman et al., 2006). Primarily,
stress and musculoskeletal discomfort contribute to the lack of
sleep. Typical musculoskeletal complaints that interfere with
sleeping are lower back pain and shoulder pain. A common belief is
that a rm mattress is benecial for low-back pain, but evidence
supporting such claims is lacking. In a survey of orthopedic
surgeons 95% believed that a mattress played a part in the
management of low back pain and 75% recommended rm or hard
mattresses for the relief of back pain (Levy and Hutton, 2000). To
compound the problem manufacturers of bedding systems make
claims relative to health benets derived from using selected
mattresses. These claims are also are largely unsupported and not
based on empirical research. Bader and Engdal (2000) found that
some mattress ads depict how the contour of the bed surface
conforms to that of the body, but they suggest that there is no
evidence that change in spine curvature is produced while
sleeping on hard or soft surfaces. In contrast, Lahm and Iaizzo
(2002) concluded that mattress ination induces changes in
spinal alignment, but with no correlation in EMG activity.
A signicant relationship between pain and sleep has been
noted (Marin et al., 2006), but few studies have compared bedding
systems or have attempted to obtain data for accurately recom-
mending mattresses for the improvement in sleep quality or
reduction in specic musculoskeletal discomfort. While some have
suggested that mattress differences do not signicantly affect
sleep quality (Sullivan, 1993; Scharf et al., 1997; Buysse and
Reynolds, 1999), most researchers agree that sleep surfaces are
*Corresponding author. Tel.: þ1 405 744 6632; fax: þ1 405 744 7758.
E-mail address: (B.H. Jacobson).
Contents lists available at ScienceDirect
Applied Ergonomics
journal homepage:
0003-6870/$ esee front matter Ó2009 Published by Elsevier Ltd.
Applied Ergonomics 42 (2010) 91e97
not alike and that some will provide better support and comfort
than others. For example, an early study found that 7% of sleep
problems were related to an uncomfortable mattress and that
comfort and support generated by the sleep surface was related to
sleep quality and efciency (Addison et al., 1986). Others have
concluded that certain sleep surfaces result in low back and
shoulder discomfort (Akgun et al., 2004; Sigman and Richmond,
1995). One study found that subjects developed back pain after
sleeping on foam mattresses (Koul et al., 2000) while another
study suggested that there was no signicant difference between
foam and innerspring mattresses in sleep stages, number of
wakes, or total sleep time (Scharf et al., 1997). Bergholdt et al.
(2008) evaluated patients with chronic low back pain using
three beds: 1) a water bed, 2) a foam mattress, and 3) a hard
mattress and found that their participants favored the water bed
and the foam mattress over the hard bed. In contrast a comparison
of beds described as hard,softer, water, and water/foam,
subjects with back pain reported reduced pain after sleeping on
hardbeds (Garn and Pye, 1981). No denition of the terms
hardor softwas included. In another study (Monsein et al.,
2000) involving patients with chronic back pain, sleep quality
and back pain were rated by visual analog scales after sleeping on:
a) subjectspersonal bed, b) an adjustable air bed, and c) again on
their personal bed. The authors found that the air bed reduced
pain and increased the quality of sleep.
While much ambiguity exists among research seeking to
establish a sleeping surface for the benet of reducing back and
shoulder pain and to increase sleep comfort, a much more consis-
tent case has been established for medium-rm sleep surfaces. In
one study Jacobson et al. (2002), found that medium-rm
mattresses reduced clinically diagnosed back pain as well as
shoulder pain and spine stiffness while positively affected sleep
quality. In other studies subjects with minor sleep disturbances
beneted signicantly in sleep quality and efciency with the
introduction of medium-rm bedding systems (Jacobson et al.,
2006, 2008). Furthermore, Kovacs et al. (2003) and Hadler and
Evans (2003) concluded that medium-rm mattresses reduce
low-back pain more so than rm mattresses. Health care practi-
tioners frequently see patients with complains of disturbed sleep,
shoulder pain, or back pain while in the bed and/or upon rising, but
little information exists for recommending a mattresses specicto
the ailment. Jacobson et al. (2002) commented on the fact that
mattresses are sold as one- type-ts-all, but recommended that
heavier individuals consider greater support in a mattress.
Since different sleeping position generate different surface
contact and pressure points it is possible that the three basic sleep
positions (supine, side, prone) require unique qualities in the
support and softness of mattress. Unsupported sleeping positions
places stress on the spine and back pain sufferers should identify
for themselves the positions that provide the most comfort. In
general, for those with back pain the two recommended sleeping
position are a) on the side with the knees drawn up (fetal position)
and b) on the back with a small pillow underneath the back of the
knees to maintain the natural curve of the lower back. Typically,
a person who suffers from pain will adopt sleeping positions that
minimize the pain (Tetley, 2000; Mayo Clinic, 2008, 2010).
While studies have focused on various surfaces in relation to
pressure sores, few have addressed mattresses in conjunction with
low back pain. Recent advancement in materials used in the
construction of mattresses has resulted in claims of greater comfort
and reduction in pressure gradients exerted by certain body areas
few studies have attempted to investigate mattress construction
based on sleeping positions. One study attempted to compare a at
bed with a at bed equipped with a specically designed lumbar
body support on ratings of discomfort in patients with low back
pain and found that that the support signicantly reduced low back
pain (Derman et al., 1995).
The purpose of this study was to assess the effectiveness of
individually prescribed medium-rm mattresses based on domi-
nant sleeping position on sleep quality and comfort in participants
diagnosed with low back pain and stiffness.
2. Methods
2.1. Participants
Subsequent to approval of the study by University Institutional
Review Board, regional chiropractic doctors were asked to refer
patients to the study who were diagnosed with lower-back pain for
three or more months. To be included in the study participants
were those without referred pain, but with presence of pain while
lying in bed or upon rising. Exclusion criteria were use of medica-
tions known to interfere with sleep, habitual prostration, possible
systemic disease, inammatory disease, cancer, bromyalgia, and
pregnancy (Kovacs et al., 2003). Of the original 43 referred patients,
27 met all criteria. Characteristics of the 27 participants included in
the study were: Females, n¼14; males, n¼13; age 44.8 yrs SD
14.6, weight 174 lb. SD 39.6, height 68.3 in. SD 3.7 (Table 1).
Personal interviews reafrmed that none of the participants pre-
sented with back, neck, arthritic or circulatory issues; degenerative,
bulging or disc fusions; type two diabetes; bromyalgia or rheu-
matoid arthritis; plates, rods or screws; or severe allergies. In
addition to demographic characteristics, visual observation as well
as height, weight, and BMI.
2.2. Procedure
Following referral by chiropractic physicians, prospective
participants were contacted and asked to complete a questionnaire
containing demographic characteristics, sleep related information
and items specic for inclusion in the study. The four items specic
to sleep were: On average, how many nights per week do you 1)
experience poor sleep quality, 2) wake up with shoulder pain, 3)
wake up with back pain, and 4) wake up with joint or muscle
stiffness? Participants recorded a number between 1 and 7 repre-
senting the number of days the condition was present during the
week. These data were again collected at the end of the study. Also,
participants were asked to provide a percentage of each position
(supine, prone, side) in which they slept. While it may be difcult
for the average individual to accurately determine their most
prominent sleeping position, typically, individuals living with pain
identify and adopt certain sleeping positions that are favored over
others in an attempt to reduce discomfort.
Participants were then given directions in how to use visual
analog scales (VASs) to assess the dependent variables (back pain,
back stiffness, quality of sleep, and comfort). With the side position
being a prominent sleeping position shoulder pain was shoulder
pain was included in the assessment.
Table 1
Participantscharacteristics. N¼26.
Mean Min Max SD
Age 44.8 25.0 76.0 14.6
Height (cm) 173.5 149.8 190.5 9.4
Weight (kg) 74.1 45.4 128.4 20.3
Side sleep 58.8 15.0 100.0 28.1
Prone sleep 31.8 0.0 85.0 23.2
Supine sleep 8.4 0.0 40.0 11.2
Bed price ($) 1090 600 1700 302.0
B.H. Jacobson et al. / Applied Ergonomics 42 (2010) 91e9792
Visual Analog Scales contain 100 mm lines with polar extreme
labels. The VAS for back and shoulder pain contained discriminate
labels of Noneand Extreme. The back stiffness VAS contained
discriminates of Extreme Stiffnessand No Stiffnessand the
VASs for sleep quality and comfort contained opposites of Excel-
lentand Very Poor. To rate each variable, participants were
asked to place a perpendicular mark along the line that best rep-
resented their perception of pain/comfort. Visual analog scales
provide an accurate measure of subjective pain and have been used
extensively in similar studies (Marin et al., 2006; Jacobson et al.,
2002, 2006, 2008; Kovacs et al., 2003; McKay et al., 2003;
Gemmell et al., 2003).
As has been done previously (Garn and Pye, 1981; Monsein
et al., 2000; Enck et al., 1999; Bader and Engdal, 2000; Jacobson
et al., 2002, 2006, 2008; McKay et al., 2003) and due to the
complex logistics and impracticality of an independent control
group design, the research format employed a single group, pre-
testeposttest design in which the subjects served as their own
controls. It has been suggested that the introduction of a control
bedding system is inappropriate in this type of study since the
introduction of a controlbedding system essentially serves as an
additional experimental bedding system and not a standard of
measurement (Jacobson et al., 2002, 2006). The current research
design followed the protocol of previous studies (Bader and Engdal,
2000; Monsein et al., 2000; Jacobson et al., 2002, 2008) in which
comparisons between experimental beds and the subjects
personal beds were made. In a previous study by Jacobson et al.
(2006) participantsbeds averaged over nine years old and the
authors suggested that it may be presumptuous to assume older
beds provide the same support and comfort as newer beds.
Therefore, in the present study, a unique criterion for standardizing
personal beds was to only include participants who slept on beds
less than ve years old.
For baseline data (pretest) subjects slept in their personal beds
for three consecutive weeks and rated Monday through Friday each
dependent variable on the VASs upon waking (Monsein et al., 2000;
Jacobson et al., 2002, 2006). Ratings were conducted by placing
a perpendicular mark through the VAS line that corresponded to
their perceptions of pain, stiffness, sleep quality and comfort.
Subjects rated the categories after sleeping in their personal beds
and were cautioned to avoid rating their sleep following heavy
alcohol consumption, trauma, or any extraordinary emotional or
physical event that could potentially interfere with sleep. If any
such non-typical changes occurred the subjects were told to rate
their sleep on a substitute day representing their typical lifestyle.
After completing the three-week baseline recordings, participants
contacted the researchers who arranged for the individually
prescribed mattresses to be delivered and installed at the partici-
pantsplace of residence. Beds were assigned based on the partic-
ipantssleeping position and anthropometric frame. For example,
for those who predominantly slept on the side, mattresses were
designed to reduce the pressure exerted by the relatively small
shoulder and hip areas.
Mattress contained layers of hypo-allergenic, non-toxic visco-
polyurethane foam (memory foam) and latex combined with
a reverse-base, steel spring component situated exclusively for
selected sleeping positions and providing a medium-rm support.
The specic materials contained in the construction of the
mattresses were: velour cover; individually pocketed coil inner-
spring units; 360 degree foam encasement; ll materials eTalalay
latex and plant oil based visco-elastic polyurethane foam (memory
foam); quilting eECO foam. Visco-polyurethane foam is developed
from polyurethane plus added chemicals that increase viscosity
and density. High density visco-polyurethane foam has an open cell
structure that utilized the individuals body temperature and
weight allowing it to mold itself to the shape of the body thus
spreading the individuals body pressure over a greater area. Latex
mattress cores are perforated with holes. The size of the holes
determined the softness of the core. The latex mattress cores
contained sections with different sized holes regulating the soft-
ness in selected areas based on the participants sleeping position.
Talalaylatex refers to the method in which the latex is formed. In
this process the rubber is agitated into foam and poured into a mold
and sealed in a vacuum. The mold is then ash-frozen to stabilize
the rubber and subsequently heated to assure evenness and
a consistent cell structure top to bottom and edge to edge. For the
current study, the foam and the latex layers were strategically
placed to provide either a softer or a rmer surface based on the
participants dominant sleeping position. For the current study one
mattress was constructed for side and back sleepers, but could be
used for supine sleepers if considered petiteor with small
anthropometric characteristics. Construction of this mattress
utilized selected thicknesses and placement of Talalay Latex and
memory foam with the prominent pressure points considered. The
mattress was also designed to support individuals of size by
considering the density of the materials between the body and the
individual pocket coils. Another mattress was designed to accom-
modate back, side, and supine sleepers by considering that the
upper and lower trunk area requires support and stability. Again
the latex and foam were of selected density and layered according
to pressure points.
Simultaneously to the delivery of the prescribed bedding
system, subjects received new VASs and were asked to rate each
variable Monday through Friday for 12 continuous weeks.
Following the protocol of others (Bader and Engdal, 2000; Jacobson
et al., 2002, 2006) and in order to reduce external, confounding
factors and to provide normalcy to the sleep environment, subjects
slept in their own bedrooms with their personal linen and pillows.
Subjects also controlled their own thermal environment. After
completing the 12-week rating, subjects submitted their VASs and
sleep questionnaires for analysis.
2.3. Statistical analysis
Data were collected via VASs on ve dependent variables (low
back pain, shoulder pain, back stiffness, sleep quality, and sleep
comfort) over a period of 15 weeks, generating 75 observations per
variable, per subject. Since the three-week pretest means were very
similar (Back pain ¼6.33 range, Shoulder pain ¼4.43 range,
Stiffness ¼2.38 range, Quality ¼5.52 range, and Comfort ¼2.37
range), the three pretest week means were averaged yielding one
three-week means to compare with posttest means. For the
Table 2
Means, standard errors, and condence intervals for back pain by time. F(12, 180) ¼
8.4093, p<0.01.
Time Mean Std. err. CI 95.00% CI þ95.00%
Pretest 50.55 3.44 43.22 57.92
Post wk1 32.64 7.21 17.26 48.02
Post wk 2 25.85 4.41 16.44 35.26
Post wk 3 20.52 3.74 12.54 28.49
Post wk 4 18.74 3.94 10.33 27.16
Post wk 5 25.66 5.93 13.01 38.31
Post wk 6 21.55 5.26 10.32 32.77
Post wk 7 21.26 5.15 10.26 32.25
Post wk 8 18.37 4.68 8.39 28.35
Post wk 9 18.66 4.93 8.15 29.17
Post wk 10 16.81 4.46 7.29 26.32
Post wk 11 16.32 3.81 8.12 24.44
Post wk 12 17.87 3.84 9.60 26.06
B.H. Jacobson et al. / Applied Ergonomics 42 (2010) 91e97 93
posttests, each 12-week mean was calculated. Data were compared
using repeated measures ANOVA accompanied by NewmaneKeuls
post-hoc tests for those variables yielding signicant Fvalues. For
the four items dealing with weekly sleep problems, Wilcoxon
Matched Pair analyses were used to compare pre- and posttests. An
alpha level of p<0.01 was considered signicant.
3. Results
Following individual determination of mattresses based on
sleeping position and mattress delivery, one participant requested
a mattress replacement after a week of rating. After reassessment
and mattress replacement the participant was satised and
continued with the study. The averagecost of the participants beds
was approximately $1090 and the average bed age was 3.2 yrs. The
primary sleeping positions were: 58.8% side, 31.8% supine, and 8.4%
Means, standard errors, and condence intervals are presented
in Tables 2e6. Analysis of the pre- and posttest means resulted in
signicant differences in back pain (F¼8.49; p<0.01), back stiff-
ness (F¼22.93; p<0.01), shoulder pain (F¼9.15; p<0.01), sleep
quality (F¼13.94; p<0.01), and sleep comfort (F¼21.33; p<0.01)
(Tables 2e5). With the exception of back pain, NewmaneKeuls
post-hoc analyses yielded signicant differences between pretest
means and for all 12-week posttests with no signicant differences
within the 12-week period. For back pain, we found signicant
differences between pretest and all 12-week posttest mean and
between the rst posttest mean and weeks 4 and weeks 8e12 (Figs.
1e3), thus indicating progressive improvement in both back pain
and stiffness while sleeping on the new mattresses.
Some have suggested that new mattresses require a break-in
period before delivering full sleep comfort (Bader and Engdal,
2000). In the current study, we saw no signicant negative
changes between the rst few posttest weeks and the week at the
end of the study, suggesting that the change was sustainable.
Analysis of the pretest mean and the 12th week posttest means
yielded the following proportional improvement: lower back
pain ¼64.6%, back stiffness ¼66.2%, shoulder pain ¼60.1%, sleep
quality ¼51.0%, and sleep comfort ¼54.8%.
Results of the Wilcoxon Matched Pairs analyses of the pre- and
posttest data regarding average number of days of discomfort per
week are presented in Table 7 and Fig. 4. Results yielded signicant
reduction in the number of nights participants experienced poor
sleep quality (Z¼3.61; p<0.01; 5.47d vs. 1.47d), shoulder pain
(Z¼3.52; p<0.01; 4.11d vs. 1.05d), back pain (Z¼3.73; p<0.01;
5.16d vs. 1.53d), and joint/muscle stiffness (Z¼2.68; p<0.01; 5.12d
vs. 2.21d).
4. Discussion
The current bed market provides a wide variety of sleep
surfaces. Beyond the traditional and most common coil spring
mattresses, newer materials such as latex and memory foam is used
in the construction of mattresses in order to provide greater
support and comfort. The density, thickness and order of layering is
considered important in considering support and comfort because
the construction and design is thought to redistribute the body
Table 5
Means, standard errors, and condence intervals for sleep quality by time. F(12,
180)¼13.947, p<¼0.01.
Time Mean Std. err. CI 95.00% CI þ95.00%
Pretest 38.20 2.94 31.91 44.48
Post wk1 68.45 5.25 57.24 79.66
Post wk 2 70.605 5.20 59.51 81.69
Post wk 3 73.48 5.13 62.54 84.40
Post wk 4 74.44 4.99 63.85 85.12
Post wk 5 71.12 5.71 58.92 83.33
Post wk 6 75.18 4.92 64.63 85.62
Post wk 7 76.67 4.48 67.11 86.24
Post wk 8 74.73 4.82 64.41 85.12
Post wk 9 76.76 4.96 66.16 87.36
Post wk 10 78.16 4.83 67.70 88.56
Post wk 11 78.62 4.38 69.39 87.94
Post wk 12 77.95 4.64 67.93 87.92
Table 6
Means, standard errors, and condence intervals for sleep comfort by time. F(12,
180)¼21.337, p¼0.01.
Time Mean Std. err. CI 95.00% CI þ95.00%
Pretest 36.02 3.17 29.25 42.78
Post wk1 70.98 5.61 59.03 82.94
Post wk 2 75.41 4.61 65.58 85.25
Post wk 3 78.24 4.25 69.18 87.31
Post wk 4 78.60 4.05 69.95 87.25
Post wk 5 80.12 3.62 72.38 87.86
Post wk 6 80.00 3.85 71.77 88.22
Post wk 7 79.35 4.29 70.20 88.50
Post wk 8 79.33 4.80 69.09 89.57
Post wk 9 78.16 5.14 67.19 89.13
Post wk 10 79.20 5.09 68.34 90.07
Post wk 11 79.95 4.61 70.11 89.80
Post wk 12 79.75 4.31 70.54 88.95
Table 4
Means, standard errors, and condence intervals for shoulder pain by time. F(12,
168) ¼9.1501, p<0¼0.01.
Time Mean Std. err. CI 95.00% CI þ95.00%
Pre-test 47.73 6.59 33.58 61.87
Post wk1 18.37 4.34 9.06 27.69
Post wk 2 15.51 3.65 7.68 23.34
Post wk 3 14.24 3.87 5.92 22.56
Post wk 4 14.33 4.03 5.67 22.99
Post wk 5 16.77 4.90 6.25 27.29
Post wk 6 17.40 4.90 6.89 27.91
Post wk 7 15.46 4.14 6.57 24.35
Post wk 8 16.38 4.51 6.70 26.07
Post wk 9 18.06 4.98 7.36 28.76
Post wk 10 20.35 6.57 6.25 34.45
Post wk 11 17.76 5.67 5.58 29.94
Post wk 12 18.31 5.43 6.66 29.95
Table 3
Means, standard errors, and condence intervals for back stiffness by time. F(12,
180)¼12.617, p<0.01.
Time Mean Std. err. CI 95.00% CI þ95.00%
Pretest 58.22 4.33 48.99 67.45
Post wk1 28.27 5.84 15.81 40.72
Post wk 2 23.56 4.87 13.17 33.94
Post wk 3 22.83 4.75 12.70 32.96
Post wk 4 20.14 4.46 10.62 29.66
Post wk 5 20.87 5.05 10.09 31.65
Post wk 6 21.35 5.10 10.47 32.23
Post wk 7 19.16 4.81 8.90 29.43
Post wk 8 19.37 4.97 8.76 29.98
Post wk 9 18.62 4.59 8.82 28.42
Post wk 10 21.66 5.25 10.47 32.86
Post wk 11 19.39 5.17 8.36 30.42
Post wk 12 19.56 4.58 9.79 29.32
B.H. Jacobson et al. / Applied Ergonomics 42 (2010) 91e9794
weight and to reduce pressure that may cause muscle and joint
discomfort. In the current study, medium-rm sleeping surfaces
constructed with layers of visco-polyurethane foam, latex and
pocked coils were prescribed for participants based on their
dominant sleeping position, weight and musculoskeletal ailment.
Studies have concluded that the sleep surface can contribute to
discomfort and that sleeping on certain sleep surfaces may be more
benecial than others (Akgun et al., 2004; Koul et al., 2000). Indeed,
it has been concluded that for those suffering from chronic low
back pain and sleep problems, quality of the mattress is relative to
the sleep quality (Lahad and Sarig-Bahat, 2007).
Previous studies have concluded that medium-rm sleep
surfaces may be the most benecial for those with chronic low back
pain (Jacobson et al., 2002, 2006; Kovacs et al., 2003; Hadler and
Evans, 2003). For instance, Jacobson and associates in two sepa-
rate studies (Jacobson et al., 2002) concluded that medium-rm
mattresses reduced clinically diagnosed back pain, and positively
affected sleep quality and that subjectswith minor, non-clinical
sleep disturbances also beneted from sleeping on medium-rm
mattresses (Jacobson et al., 2002). Others have also concluded that,
medium-rm mattresses can reduce low-back pain more so than
rm mattresses (Hadler and Evans, 2003) and that medium-rm
mattress may be more benecial than a rm mattress in matters of
back pain, pain on rising, and daytime back pain (Kovacs et al.,
2003). Consistent with these suggestions, Israeli guidelines for
prevention of low back pain, based on recommendations of the
Europiena Commisitono, COSST Action B13 states that persisting
low back pain symptoms may be reduced with a medium erm
rather than a hard mattress (Lahad and Sarig-Bahat, 2007). The
uniqueness of the present study was the attempt to individually
prescribe mattresses based on sleeping positions and the utilization
of both visco-elastic polyurethane foam and Talalay latex to
distribute pressure over a greater surface area generated by the
prominent sleeping position. Most previous studies have utilized
coil spring mattresses.
It has been suggested (Bader and Engdal, 2000) that a pseudo-
placebo effectmay be responsible for initial high comfort ratings,
however, such perception eventually wear off with time. These data
indicate that the benets derived from the new mattresses were
immediate and continued over a 12-week period. Furthermore, the
robust improvements stemming from the questionnaire given prior
to the onset of the study and again at the end of 12 weeks provide
further evidence of sustainability.
Bader and Engdal (2000) suggested that new mattresses require
a certain amount of break-in time to deliver full benets. In the
present study, signicant reductions in pain and stiffness and
increases in sleep quality and comfort were realized in the rst
week and were sustained over the duration of the study. It is
plausible that the newer materials used in the mattress construc-
tion requires no actual break-in time.
Similarly to the pseudo-placebo effect it may be argued that the
participants preferred the experimental mattresses because they
were new and provided at no cost, thus generating an obligatory
response akin to a Rosenthal effect. Jacobson et al. (2008)
acknowledged that new beds provided at no cost may inuence
participants to overrate the benets of the bed. They suggest that
such a phenomenon is minimized when subjects are not given any
information about the expected outcome of the study and any
perceived obligation would subside over time. Additionally, for the
present study, all pretest data was submitted to the researchers
prior to rating the new mattresses, making it impossible for the
participants to compare pretest with posttest data.
The possibility of a Hawthorn effect may also threaten research
results. A related study used the common denition of the Haw-
thorne effect as the suggestion that people will respond to any
novel change, not because of any specic condition being tested,
Fig. 3. Pre- and post12-week means for sleep quality and comfort.
Table 7
Wilcoxon matched pair analysis for pre- and posttest means by weekly sleep items.
Items Mean SE tdf
Poor sleep quality
Pretest 5.47 1.80 7.48* 18
Posttest 1.47 1.80
Shoulder pain
Pretest 4.10 2.23 5.61* 18
Posttest 1.05 1.80
Back pain
Pretest 5.15 1.80 8.64* 18
Posttest 1.52 1.64
Back stiffness
Pretest 5.10 2.18 3.88* 18
Posttest 2.21 2.12
Fig. 1. Pre- and 12-week post means for back pain and stiffness.
Fig. 2. Pre- and 12-week post means for shoulder pain.
B.H. Jacobson et al. / Applied Ergonomics 42 (2010) 91e97 95
but because of the attention they receive (Jacobson et al., 2008).
Similarly to previous studies (Jacobson et al., 2002, 2006, 2008)
participants were not personally monitored over the 12-week
experimental period except for follow-up calls to assure compli-
ance in lling out the daily VASs.
5. Conclusion
Conclusions following previous research (Jacobson et al., 2002,
2008) have centered on the dearth of knowledge regarding sleep
surfaces and the need to continue to compare and assess
mattresses. Of particular interest and importance is the distinct
possibility that a properly tted mattress can reduce common
musculoskeletal pain and improve sleep quality and comfort. The
current study supports the growing evidence that medium-rm
mattresses are suitable in providing sleep quality and comfort.
These data provide impetus for continued research in determining
the effectiveness of specically constructed sleep surfaces based on
sleeping positions in order to enhance sleep quality and to reduce
musculoskeletal pain. In the current study the participants expe-
rienced considerable improvement in quality sleep (73%), shoulder
pain (75%), back pain (70%), and joint/muscle stiffness (57%)
following 12-weeks of sleeping on the new mattresses.
A previous study suggested that the average age of their
participantsbeds (9.5 yrs) may have contributed to a slow
progression of poor sleep and musculoskeletal discomfort due to
a deterioration of support provided by the beds over the years
(Jacobson et al., 2002). To reduce the possibility of replacing a very
old bed, the current study controlled for the age of the participants
beds by only including those with beds ve years or younger in
order to reduce any confounding variables attributed to bed age.
Longevity and durability of mattresses are difcult to determine,
but the Better Sleep Council (2009) suggest that the lifeof
a mattress depends on original quality, usage and recommend that
the sleep surface be evaluated after ve to seven years. Newer
materials such as latex and visco-elastic polyurethane foam are
resilient and durable, but changes in anthropometrics, chronic pain,
and aging may also require a change in the bedding system.
Jacobson et al. (2002) concluded that new mattresses can signi-
cantly improve sleep and that sleep quality may be dependent on
timely replacement of mattresses.
An inherent and unresolved issue centers around terms such as
rmand softwhich are not globally dened either in the
market place or in research. Yet, these data support both the benet
of a medium-rmsleep surface constructed of layers of visco-
elastic polyurethane foam and latex and the suitability of
prescribing the sleep surface based on the prominent sleeping
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... Previous studies have reported that the sizes, forms and nature of sleeping surfaces may influence body biomechanics and the occurrence of joint pain (Ancuelle, et al, 2015;Low, et al, 2016;Wong, et al, 2019). Both latex and memory foam mattresses are reported to provide a unique feel that relieves pressure on painful joints (Jacobson, et al., 2010). Also, studies posit that there is a bi-directional relationship between sleep disturbance and pain intensity, an implication that each of pain and disturbed sleep are capable of eliciting one another (Alsaadi, et al., 2014a;Alsaadi, et al., 2014b). ...
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Certain sleep surfaces may trigger complaints of musculoskeletal pain and discomfort among otherwise healthy individuals. Thus, studies investigating the association between sleep surfaces and the prevalence of musculoskeletal pain and discomfort are imperative. This study investigated the influence of sleep surfaces on musculoskeletal pain among undergraduate students in Lagos, Nigeria. Five hundred undergraduate students of the College of Medicine University of Lagos from 300 to 600 level participated in this cross-sectional survey. They completed a 47-item modified Standardized Nordic Questionnaire for the analysis of musculoskeletal symptoms. Information sought included respondent's demographics, mattress characteristics, sleeping pattern, prevalence of musculoskeletal pain, location, predisposing factors, treatment approaches adopted and knowledge of ergonomics. Data was summarized using descriptive statistics of frequency, mean, standard deviation, percentages, and inferential statistics of chi-square to test for association among variables. Level of significance was set at p ≤ 0.05. A 12-month 79.7% prevalence of musculoskeletal pain was observed with females significantly (p<0.05) higher than males (57.9% vs 42.1%). The highest 12-month prevalence of musculoskeletal pain was on the low back (17.6%), while the highest point prevalence was on the neck (54.6%). Mattress type, size and duration of use were not significantly (p>0.05) associated with the prevalence of musculoskeletal pain among undergraduate students. Prevalence of musculoskeletal pain among undergraduate students was high, more in females than males. Mattress type were not significantly associated with the prevalence of musculoskeletal pain among undergraduate students.
... 14,15 It has been known that a mattress with insufficient force dispersion could not improve poor sleep quality. 16 Previous study indicated that the cardboard bed with a blanket could not improve sleep EEG indexes in two-hour nap compared to the blanket on the floor. 8 However, their trial was conducted in February, and the room temperature was maintained 15°C. ...
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Objective This study aimed to describe and evaluate the dispersion of body-mattress contact pressure on a cardboard bed and investigate whether the cardboard bed has a positive effect on evacuees’ musculoskeletal burden. Materials and Methods A high-performance nursing simulator was used to measure the contact pressure and the body surface contour area of the bed, and these values were collected with the patient in the supine position using the Body Pressure Measurement System. Data of each test were acquired 10 times and were compared among 4 conditions (plastic sheet, cardboard bed, cardboard bed with a blanket, and cardboard bed with a mattress-topper). The data analysis for body-mattress contacts pressure and the surface contour area of the whole body, head, chest, and buttocks were conducted by one-way repeated analysis of variance and Bonferroni post-hoc test. Results The average body-contact pressure on the cardboard bed did not decrease compared with that on the floor with plastic sheets. In contrast, the body surface contour area was significantly different among any other conditions, but the gap was only approximately 16%. However, the body-contact pressure and the body surface contour area were improved when a mattress-topper was added on the cardboard bed. When a blanket was laid on the cardboard bed, the contact area was increased. Conclusion Our results indicate that the pressure dispersion ability of the cardboard bed was not sufficient; however, adding the mattress-topper or the blanket could contribute to an improvement in the evacuees’ musculoskeletal burden. Many evacuees lay a mattress topper or futon on a cardboard bed after installing cardboard beds. Our findings may also support the scientific validity of the evacuees’ actual sleeping style in Japan. This preliminary study provides the basis for future research on exploring an appropriate sleeping bed condition in evacuee shelters.
... Several authors evaluating the relationship between mattress design and sleep quality studied materials and structural properties of spring mattresses [17]. No significant correlation was found between mattress firmness and sleep quality. ...
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Energy spent during daily activities is recuperated by humans through sleep, ensuring optimal performance on the following day. Sleep disturbances are common: a meta-analysis on sleep quality showed that 15-30% of adults report sleep disorders, such as sleep onset latency (SOL), insufficient duration of sleep and frequently waking up at night. Low back pain (LBP) has been identified as one of the main causes of poor sleep quality. Literature findings are discordant on the type of mattress that might prevent onset of back pain, resulting in an improved quality of sleep. We conducted a systematic literature review of articles published until 2019, investigating the association of different mattresses with sleep quality and low back pain. Based on examined studies, mattresses were classified according to the European Committee for Standardization (2000) as: soft, medium-firm, extra-firm or mattresses customized for patients affected by supine decubitus. A total of 39 qualified articles have been included in the current systematic review. Results of this systematic review show that a medium-firm mattress promotes comfort, sleep quality and rachis alignment.
... Coaches were asked to make a perpendicular mark on the line that best represented their perception of each player's specific ability for each of the five dependent variables: Overall Basketball IQ, Offensive IQ, Defensive IQ, Anticipation Ability, and Passing ability. A VAS provides an accurate measure of subjective perceptions and has been used extensively in prior studies (e.g., Boolani, 2017;Jacobson, 2010;Wittwer, 2016). Two research assistants scored the VAS and entered the scores into SPSS. ...
... In the case of sofa beds, the results show that the maximum of the magnetic field is at the height of the head, i.e. approximately in the occipital part of the head. Some knowledge from the literature [6,10,14] indicates a possible impact on the clogging of blood vessels in the area of the nape and head and the increase in blood pressure. ...
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Ferromagnetic elements in the furniture, especially beds, influence the changes in the magnetic field distribution in this area. In this way, an inhomogeneous magnetic field whose values are higher than the Earth’s natural magnetic field is generated. The presence of humans or their body parts in anomalous magnetic fields has become the focus of health concerns. For this reason, the magnetic field for different types of beds with ferromagnetic parts, such as mattresses, has been calculated in this paper. Our results showed that exposure to magnetic fields revealed the zones with higher magnetic induction for some type of beds. In the end, new material and new design processes have been suggested in order to maintain a healthy lifestyle.
... Good sleeping quality can help facilitate a healthy circadian rhythm, reduce muscle fatigue, and increase fatigue recovery of the body (Khaleghipour et al., 2015;Huysmans et al., 2006). In contrast, lack of sleep influences social interactions and personal mood and decreases the quality of life (Jacobson et al., 2010). Selecting a properly designed sleeping system, including a pillow, mattress, support structure, and cushion, has a direct relationship to sleep quality (Vitale et al., 2018;Kr€ auchi et al., 2018). ...
Placing a topper on a sleeping system is common practice to enhance sleeping comfort. The aim of this study was to determine the thickness and hardness effect of a mattress topper by measuring the four physiological measurements from 40 healthy males. The results showed that the use of a thin mattress topper (30 mm) significantly induced lower body pressure and temperature, higher muscle activities in the biceps femoris, and a straighter spinal alignment in the T12–L4 vertebrae. The use of a hard mattress topper significantly induced a higher body pressure, a lower body temperature in the lower extremities, a higher EMG (%MVC) in the trapezius, but a lower EMG (%MVC) in the biceps femoris, and a straighter spinal alignment at T1–T4, T4–T6, and T6–T8. Overall, a soft topper of 30-mm thickness was suggested as the best combination. The findings can provide very useful information for topper design and selection.
... While sleep is mainly disturbed by multiple environmental factors (e. g. noise, temperature, lightning, and air quality) (Caddick et al., 2018), a comfortable bedding system is essential to attain a quality sleep (Lee and Park, 2006;Jacobson et al., 2010;Verhaert et al., 2012). On this regard, distribution of contact pressures is a well-established and objective indicator for the comfort and biomechanical quality of supporting systems in lying (Nicol and Rusteberg, 1993;Park et al., 2001) and sitting (Zemp et al., 2015;Looze et al., 2003). ...
Occupants of autonomous vehicle have frequently indicated the desire to sleep or rest while driving, yet little has been known regarding the suitable design criteria for a biomechanically reasoned in-vehicle sleeping position. This study was aimed at evaluating the biomechanical quality of different backrest and seat pan angle combinations, and at predicting the most favourable sleeping positions based on vehicle restriction. More specifically, the interface pressure distribution and subjective suitability rating of 23 subjects was assessed in a total of nine (3 × 3) combinations of seat pan (20°, 30°, 40°) and backrest (145°, 155°, 165°) angles. Biomechanical quality was evaluated with an interface pressure score (IPS) based on sensitivity weighted pressures and the total contact area. Two-way repeated measures ANOVA revealed that IPS significantly improves with increasing seat pan angle whereas backrest angles of 155° or 165° lead to significant better IPS compared to flatter ones (145°). The overall highest IPS was observed for a 40°-seat pan angle in combination with a 155°-backrest angle. Subjective suitability rating revealed that people prefer a combination of 165° backrest angle with a seat pan of 20°; however, eight of nine combinations can be considered as suitable for sleeping. Therefore, the combination of a 40°-seat pan angle and 155° backrest is recommended by the present study for an in-vehicle sleeping position due to the increased biomechanical quality.
Infancy is a developmental stage in an individual's life. As an important part of infant development, sleep greatly influences the physiological and mental development of infants, and the health and comfort of infant sleep is a major public concern. From the viewpoint of ergonomics, this study investigated the effects of mattress firmness on the body pressure distribution of infants aged 0–3 years in the supine posture. Six types of mattresses with different firmness values were tested and 11 healthy infant subjects participated in the experiment. A Tekscan body pressure measurement system was used to record data. The body pressure distribution of infants was analysed using six pressure distribution indices including the maximum pressure, average pressure, contact area, maximum pressure gradient, average pressure gradient, and longitudinal pressure distribution curve. The results revealed that, in the supine posture, there is significant correlation between the body pressure indices and the mattress firmness. The average pressure has the strongest correlation with mattress firmness. The infants' buttocks zone had the highest pressure, while the pressure on the head and leg zones was relatively low. The recommended K value, which represents the mattress firmness, ranges from 267 to 669 mm².
Complex tests and procedures brief are not usually needed to identify shoulder injuries that are common in clinical practice: rotator cuff injuries, shoulder instability, and impingement syndrome, among others. The history can differentiate causes of pain or instability with questions about symptom patterns. Performing targeted physical tests such as the drop-arm test and the apprehension test establishes presence and degree of impingement or instability. A standard radiographic series that includes rotation, axillary, and supraspinatus outlet views can identify presence of associated fractures, calcification, and lesions.
To compare personal and new bedding systems between subjects with reported high and low base line sleep quality. A convenience sample of healthy subjects (women = 30; men = 29) with no clinical history of disturbed sleep participated in the study. Subjects recorded perceived back discomfort and stiffness, sleep quality and comfort, and sleep efficiency upon waking for 28 consecutive days in their own beds (baseline) and for 28 consecutive days (post) on a new bedding system. Repeated measures analysis of variance was used to treat sleep data. Analysis revealed significant differences between pre- and post means in all areas for both high and low sleep quality groups. Analysis of sleep efficiency also yielded significant differences between, but not among pre- and post means. Improvement of sleep comfort and quality became more prominent with time (from wk 1 to 4 post observation). Similar significant benefits of new, medium- firm bedding systems can occur for those reporting both good and poor current sleep quality and variables such as age, weight, height, and body mass index are independent of such improvements.
This study examines the effect of 4 different types of beds on chronic low back pain patients' symptoms and signs. The beds employed were an "orthopedic" hard bed with 720 reinforced coils and a built-in bed board, a softer 500 coil bed, a standard 10 in. thick waterbed, and a hybrid bed of foam and water. Subjectively the majority of patients preferred the hard bed and felt that their back pain improved to a greater extent after 2 weeks on the hard bed as compared to the other beds. The next largest group of patients to show improvement used the waterbed. Limitations in performing the straight leg raising test coincided with the subjective complaints. Significantly improved straight leg raising was observed after use of the hard bed or waterbed in 25% of the patients using those beds. No other objective signs were altered. The 500 coil bed and the hybrid bed proved of no benefit to any patient in this study group. This limited study indicates that hard beds should remain the first choice of patients with chronic low back pain. However, if relief is not obtained for these chronic pain patients, a trial on a waterbed may prove beneficial.
To determine the effects of a locally designed lumbar body support (LBS) on integrated electromyographic (IEMG) activity of the lumbar erector spinae muscles, on heart rate and on ratings of discomfort in patients with low back pain. Non-randomised controlled trial. Patients referred from general practitioners and back pain rehabilitation programmes in Cape Town. Ten patients with low back pain of diverse causes. Values were compared with those in 10 control subjects without low back pain. Patients and controls lay supine on (in random order) either a flat conventional mattress or a LBS placed on top of the flat mattress, for a 30-minute period (acute exposure), and every night for 2 weeks (chronic exposure). IEMG activity of the lumbar erector spinae muscles, heart rate, and perception of comfort. IEMG activity of the lumbar erector spinae muscles did not differ between controls and patients when lying on the LBS on top of the CM after either acute or chronic exposure. However, it was significantly greater (P < 0.05) in patients than in controls when lying on the flat mattress. Subjective ratings of discomfort and heart rates mirrored these changes and were higher in patients only when lying on the flat mattress (P < 0.05). Patients with low back pain also reported that sleeping overnight on the LBS on top of their own mattress significantly reduced discomfort ratings. When lying on a mattress with a flat surface, patients with chronic low back pain have higher IEMG activity of the erector spinae muscles, higher heart rates and higher subjective ratings of discomfort than do control subjects. These differences disappear when both groups use a specially designed lumbar body support placed on top of the flat surface. These preliminary studies suggest that a lumbar body support should be evaluated in the chronic management of low back pain.
The comparative effects of sleep patterns and rates of cyclic alternating patterns (CAP rate) in a high quality innerspring mattress were compared to those on a unique foam support mattress in 10 normal subjects. Results showed no differences in sleep stages, number of wakes, or total sleep time between the two conditions. CAP rates were significantly reduced on the foam surface. CAP rate was sensitive to the first-night effect on both surfaces, but was blunted on the foam mattress.
Insomnia is an extremely common symptom both de novo and in the context of other medical and psychiatric disorders. The impact of insomnia is often ignored both by the individual and by society in terms of its clinical and socioeconomic ramifications. Insomnia is therefore under-appreciated and almost certainly under-treated, thus making it a serious health concern. It is estimated that more than 60 million Americans suffer from insomnia annually, and this figure is expected to grow to 100 million by the middle of the 21st century. Whether it be difficulty initiating or maintaining sleep, the disruption of nocturnal sleep will invariably impact on daytime activities and often results in daytime fatigue, performance deficits (including memory and other cognitive deficits), an increase in the number of sick days taken by an individual and accidents (some catastrophic). This review examines the costs directly related to insomnia in various sectors of healthcare, the indirect costs associated with accidents, sick days and decreased work productivity, and related costs resulting from insomnia but which meet neither the criteria of direct nor indirect cost categories. The total direct, indirect and related costs of insomnia are conservatively estimated at $US30 to 35 billion annually in the US (1994 dollars). Economic gains can be made by treating patients on an outpatient basis in sleep centres.
We studied the relationship between sleep quality and bed surface firmness. Nine men were investigated, sleeping in their homes for at least 5 consecutive nights on a soft and a more firm mattress using a sensor pad placed under the mattress and a solid-state recording device. The subjective feeling of sleep quality did not always agree with the recorded sleep data. The difference was most marked when changing from the subject's own to one of the test mattresses. For the same subject the results were reproducible between nights provided there were no external disturbing factors. Four of the 9 subjects slept significantly better on the softer of the two mattresses and 2 on the hard mattress. The difference in sleep quality observed among the subjects tested makes it necessary to relate the results to the same person rather than considering a whole group as an entity. The adaptation period for a new sleep surface extended to many days.
To compare SF-36, pain Visual Analog Scale (VAS), and sleep VAS outcomes of an adjustable airbed with innerspring mattresses in a population of chronic back pain sufferers. A-B-A trial, in 3 phases: the patients on their own bed for 1 night, on an adjustable airbed for 28 nights, and on their bed for 14 nights. Outpatient pain rehabilitation, physical therapy, and alternative medicine clinics. Three centers recruited 30 patients each with severe chronic back pain and without sleep apnea or other sleep disorders. SF-36 health status survey and VAS pain and sleep quality scales. On VAS scales, 95% showed pain improvement, and 88% reported better sleep. The average improvements were a 32% pain decrease and a 73% increase in sleep quality, significant at P less than.001 (two-tail t test). Eighty percent improved on the SF-36 physical functioning dimension and 88% improved on the bodily pain dimension. The average score on each dimension improved (P less than.001). Eighty-five percent preferred the adjustable airbed. SF-36 and VAS outcomes measures showed a highly significant benefit for the airbed design in this short-term comparison. The airbed appears to be a useful sleep aid and an adjunct to medical and physical therapies for chronic back pain sufferers.