By Tom Fontana, MSPT
When the monthly magazine I subscribe to that reports on consumer issues arrived rating mattresses, I read the article with great interest as sleep-related questions are ones we often get, particularly from patients with back or neck pain. I appreciate their thoroughness and the ingenious lengths they go to in order to test the quality of products and that actual tester experience factors into their ratings. I was doubly excited when the caption on the introductory graphic said they would make recommendations no matter what your preferred sleeping position (I’m paraphrasing) and the graphic showed people sleeping in all kinds of sleep positions including prone (i.e., stomach sleeping—and I have to admit, as much as I was interested professionally, I have self-interest as this is my preferred sleep position—I know, TMI).
Much to my chagrin, early in the body of the article it said that to gauge firmness they would measure “how much support each mattress provides to people of different sizes, whether they sleep on their back or on their side (emphasis mine) and the ratings they provided were for mattresses that were best for back or side sleepers. Wait! What about us belly sleepers!? Nary a peep.
In years past, I seem to recall they gave some kind of lip service to this omission by saying something like, “We talked to experts and they said people shouldn’t sleep on their stomachs so we decided not to address that” but this year they didn’t even mention prone sleeping as an option. It’s as if because some experts said it shouldn’t happen that it doesn’t exist, cleansed from existence, like a Thanos finger snap. But, if it’s so bad for us, why do so many of us want to do it/feel more comfortable sleeping that way? It reminds me of the title of Elvis Presley’s Gold Records, Vol. 2, “50,000,000 Elvis Fans Can’t Be Wrong.” Is prone sleeping really SOOOOOO bad that people just shouldn’t do it, or is this the population that might BEST benefit from advice on what to purchase in order to be more comfortable?
I don’t entirely blame them as this is “conventional wisdom” amongst “experts” but, in this age of evidence-based medicine, I wondered what evidence exists that prone sleeping is not good for you. I ran a search on prone sleeping on PubMed, the online search engine for the database of journal articles and abstracts managed by the United States National Library of Medicine at the National Institutes of Health. (Please note, this story and its recommendations are related to ADULTS sleeping on their stomachs NOT INFANTS; there is STRONG, CONSISTENT EVIDENCE that infants should NOT sleep prone due to this position’s increased risk of Sudden Infant Death Syndrome.)
It was actually very difficult to find articles on adults sleeping prone! There were articles on how to best measure pressure points, comfort levels with different materials and mattress shapes, the use of computing and artificial intelligence to model body position-mattress interaction, the use of the prone position for those with sleep apnea (it’s generally positive as it reduces snoring and unwanted movement of the soft palate), facial wrinkles (it might lead to certain kinds of wrinkles), and the health of vertebrobasilar arteries (chronic significant head turn may compromise arterial health). What I did NOT find was any research study on sleeping prone and neck or back pain!
So, essentially this is conventional wisdom because it is conventional wisdom. Perhaps it’s just easier for magazines and experts to tell you not to do something than to take the time to explain it. Now, I am NOT saying that there aren’t conditions for which prone sleeping would be ill advised, among them: hiatal hernias/GERD (involving stomach acid moving into the esophagus), carotid arterial disease/blood flow compromise to the brain, or lumbar or cervical stenosis (a narrowing of the openings through which spinal nerves exit), though this last one perhaps could be worked around with the right education/equipment.
When the spine bends backwards the joints approximate and prone sleeping may not feel good even in a healthy spine (with a saggy mattress) and even less good if one has arthritis (even with a less saggy mattress). This may account for why prone sleeping was found to be more popular among young individuals and less popular as we age.
So, what should you do if you want to be a belly sleeper? Here is my recommendation, but realize it is just my opinion (along with 50+ years of experience!) and not based on scientific evidence. Since you want to avoid a saggy mattress, you should gravitate toward ones that are firm. How firm? However firm is necessary to feel good to you. Also, since you want this to remain firm for a long time (most people like to buy mattresses as often as they buy houses), don’t skimp and buy a cheap brand that will break down in a year or two (usually the day after the warranty runs out!). For reputable brands, I would refer to popular consumer reporting magazines/websites.
As a general rule when selecting a mattress, lay on a whole bunch of different mattresses. You will soon learn which types feel awful immediately and you will start to narrow your search. Within those types, to whittle down the semifinalists it may take up to 20 minutes or so for you to develop discomfort from pressure points so you should plan to spend a long time laying on mattresses. (This will usually be more time than any mattress salesperson wants to spend with you. Don’t be pressured. There are many wonderful, knowledgeable salespeople out there but if you experience one that is getting frustrated with you and is more interested in making a sale than finding you the right mattress, I usually find mentioning something about your physical therapist recommended you do this and then mention back pain or a medical condition, whether you have it or not, and I usually see their eyes roll back into their heads and they leave you alone.) If you are comfortable laying on it for 20 minutes or more in your usual sleep position, there is a good likelihood you will be comfortable on it.
In terms of neck pain, mattress selection is not as important as pillow selection and head position. I don’t have a huge preference as to pillow composition but more about pillow SIZE. If you have a fat pillow that won’t compress, this tends to push your head away from the mattress and extends your neck. Coupled with turning to the side, that could be a real pain in the neck when you wake up. So, select a fairly thin pillow (how thin?—however thin feels good to you) and make sure you sleep toward the side of the pillow so your face is really facing forward more than it is to the side. Following these steps will reduce the likely negative effects that make experts want you to avoid the position altogether.
Not good Good
In the conclusion of Wong et al.’s article, “Sleeping mattress determinants and evaluation: a biomechanical review and critique” from the 2019 journal PeerJ, they state: “Mattress design and selection to achieve client satisfaction are recognized as a tedious trial-and-error process. This broad review was conducted to systematically sample the relevant information and thus improve the process of mattress design and selection as well as stimulate pertinent standard setup. While the studies implemented personalized design, cutting edge technology and algorithm to improve mattress design, the basic requirement of mattress design is inconclusive” (emphasis mine). In other words, at the end of the day take what experts recommend but, at least at this stage of sleep/mattress research, there’s no one thing to tell everyone to do or not to do. You know what feels best to your body and if it feels good, do it! Congratulations, for sticking it out to the end of this article–now you know why it’s easier for experts to just tell you not to do it!