The effects of gravity inversion procedur es
on systemic blood pressure,
intraocula r pressure, and
central retinal arterial pressure
RONALD M. KLATZ, D.O.
ROBERT M. GOLDMAN, B.S.
BURTON G. PINCHUK, o.D.
KENNETH E. NELSON, D.O.
ROBERTS. TARR, PH.D.
Chicago, Illinois
Gravity Inversion Boots (a device
which clasps around the ankle joint
and hooks onto a stationary
horizontal bar allowing one to hang
stationary in an inverted, head down
position) is a popular method for
traction and exercise now being used
by an estimated one million people.
Recent reports in the medical
literature suggest that this device
may be contraindicated in patients
with hypertension, cardiovascular
disease, and ocular problems. In an
effort to document physiologic
changes which occur in the inverted
position, twenty healthy medical
students were subjected to a 3-minute
inactive period of inversion. Systemic
blood pressure, pulse rates, central
retinal arterial pressure, and
intraocular pressures were measured
and found to be significantly elevated
in all subjects. We speculate that this
device may be contraindicated in
certain patient populations,
specifically hypertensives. Caution is
advised in relation to people with
spinal instability, suspected
abnormalities in hemostasis, or with
intraocular hypertension.
Gravity inversion boots are devices that clasp
around the ankle joint and permit an individual to
hang from a stationary horizontal bar in a totally
inverted ( -90° head down) position. Inversion
boots were first designed by Martin, 1 a California
Effects of gravity inversion procedures
orthopedic surgeon, as a traction device to relieve
interspinal disk pressures. The boots allow the
participant to utilize gravity and one' s body
weight to decompress the spine. Since their devel-
opment in the late 1960s, gravity inversion boots
have enjoyed widespread use, including many un-
likely applications such as weight lifting while in
the inverted position. 1 · 4
The manufacturers have attempted to inform
potential purchasers about the contraindications
to gravity inversion therapy: uncompensated con-
gestive heart failure, uncontrolled hypertension,
carotid artery stenosis, and hiatal hernia. 6 There
have been reports of individuals suffering perior-
bital petechiae, 5 headaches, and sensations of
head pressure. 6
A review of the medical and aerospace literature
yielded little information on the effects of total in-
version. According to estimates from the various
manufacturers' data, as many as one million
Americans may be engaging in this activity.
Therefore, we thought it important to study the ef-
fects of inversion on systemic blood pressure, pulse
rate, central retinal arterial pressure, and intra-
ocular pressure.
Materials and methods
Eighteen male and two female subjects, ranging in
age from 22 to 33 years, were chosen from the stu-
dent body of the Chicago College of Osteopathic
Medicine. The volunteers had no medical history
of hypertension or glaucoma.
The subjects were seated and resting blood pres-
sure, pulse rate, central retinal arterial pressure,
and intraocular pressure were measured. The sub-
jects were then inverted for a 3-minute-period.
During the inversion period, systemic blood pres-
sure was measured at 45 seconds and at 3 minutes;
pulse rate was measured at 1 minute; and central
retinal arterial pressure and intraocular pressure
were both measured at 3 minutes. The subjects
853/111
 Fig. 1. Blood pressure values of subjects were recorded at 45 seconds
and 3 minutes while in the inverted position. Fig. 2. Intraocular and
central retinal artery pressures were recorded with the MacKay-Marg
applanation tonometer at 3 minutes while in the inverted position.

were then returned to the seated position. All four
parameters were remeasured within 1 minute
after the subject was returned to the upright pos-
ture, with the subject seated.
Pulse rates were taken from the radial pulse of
the right wrist. A Propper sphygmoman ometer
and a Litmann cardiology stethoscope were em-
ployed to measure blood pressure with the right
arm supported laterally at the heart level for all
measurements (Fig. 1). Intraocular pressure was
measured utilizing a MacKay-Marg Model12 ap-
planation tonometer (Fig. 2). Ophthalmodynamom-
etry was used to measure central retinal arterial
pressure. 7 In this technique, the instrument probe
of the tonometer was placed on the sclera of the
anesthetized eye (1-2 drops 0.5 percent propara-
caine HCl) just adjacent to the limbus. The arte-
ries were visualized using a direct ophthalmoscope
at the optic disc. At first pulsation of the arte-
ries, the pressure was recorded. The pressure on
the globe was then continually increased until pul-
sation ceased. The first pulsation was recorded as
the diastolic pressure; the latter as the systolic
pressure.
Means and standard errors were calculated for
the following parameters: systemic systolic blood
pressure, systemic diastolic blood pressure, pulse
rate, central retinal systolic arterial pressure, cen-
tral retin'al diastolic arterial pressure, and intra-
ocular pressure. The primary method of statistical
analysis was an overall analysis of variance for
each of these parameters. To determine the signifi-
cant sources of variation, analysis of variance was
used again to make multiple comparisons between
adjacent time intervals. 8
Results
Systemic blood pressure and pulse rate
Both systolic and diastolic pressures increased on
inversion, remained relatively constant during in-
version, and returned to normal on resuming an
upright posture. Table 1 and Figure 3 show blood
pressure levels before, during, and following in-
version. Analysis of variance indicates that the
rise observed when subjects were inverted and the
drop observed when normal posture was resumed
were highly significant (p<.001). During the in-
version period the blood pressures fell slightly, but

854/112 July 1983/Journal of AONvol. 82/no. 11

 only the change in systolic pressure was signifi-
cant (p< .05).
Pulse rate prior to inversion was 67 ± 1.44.
After 1 minute of inversion, the average rate was
78 ± 1.09 (p< .001). One minute after resuming an
upright posture, the pulse rate was still signifi-
cantly elevated (75 ± 1.71) above pre-inversion
levels.
Central retinal arterial pressure
and intraocular pressure
Systolic central retinal pressure, diastolic central
retinal pressure, and intraocular pressure all in-
creased (p< .001) on inversion and returned to nor-
mal on resuming an upright posture. Table 2 and
Figures 4 and 5 show these pressures before, dur-
ing, and following inversion. The central retinal
systolic and diastolic blood pressures and the in-
traocular pressure were all significantly elevated
during inversion. No significant differences were
found between pre-inversion and post-inversion
values. Central retinal arterial pressures had a
tendency to remain slightly elevated in the post-
inversion period, but this was not statistically sig-
nificant.
Discussion
mately 500 ml. ofbl~od are pooled in the legs. This
can result in a decreased cardiac output of 2 liters/
minute and a 40 percent reduction in stroke vol-
ume.9
It is reasonable to speculate that in the inverted
position the right atria of the heart would receive
at least an extra 500 ml. of venous blood which, ac-
cording to Starling's Law, would increase cardiac
output and also raise systemic blood pressure. It
should be noted, however, that emotional and psy-
chologic factors could have contributed to the ob-
served increases in systemic blood pressure. In
fact, the increase in pulse rate suggests a neural
component to the rise in blood pressure. In a study
of six human subjects placed in a -20° head down
position for 3 hours, Katkov and associates 10 found
changes in ventricular systolic pressure consistent
with increased headward blood shifts. These find-
ings include elevated right ventricular pressures
and decreased left ventricular pressures. In his
study, Katkov found increased pulse rate and
gradually decreasing systolic and diastolic blood
pressure values.10 This last finding was inconsis-
BLOOD PRESSURE MEASUREMENTS DURING INVE RSION

The results of our study indicated a rise in blood

pressure, pulse rates, retinal arterial pressures, 160

and intraocular pressures despite the subject's

lack of physical activity while in the inverted posi-
tion. 120
The effects of gravity on the physiology of hemo-
dynamics are such that distensible blood vessels
experience variable responses in pressure and
1 1
flow. For example, if a 5-foot 7-inch tall subject in iii., 80
DIASTOLIC
the standing position had a mean arterial blood ~
J::
E
pressure (MAP) at the level of the heart of 100 mm. .s
~
Hg, then the MAP at the level of the feet (130 em. ~

below the level of the heart) would be (100 + 95) = £ 40

195 mm. Hg (each em. of blood exerts a pressure 8

iii

equivalent to .735 mm. Hg) . Conversely, the MAP

in the cerebral artery (located approximately 46
em. above the level of the heart) would be (100 - Pre- inversion
0
Inversion Period
4
Post- inwrsion
34) = 66 mm. Hg. Because of this effect, it has Measured m Minutes

been estimated that when an individual shifts * Siqnificonfly different (p< .OOI) fr om both pre -inversion and post-inversion.
No differences were found between pre- and post-i nversioo va lues.
from the supine to the standing position, approxi-
Fig. 3. Graph depicting blood pressure variation with change in
posture.
TABLE 1. SYSTOLIC AND DIASTOLIC SYSTEMIC BLOOD PRESSURE BEFORE, DURING, AND FOLLOWING INVERSION. VALUES SHOWN ARE MEAN
AND STANDARD ERROR FOR 20 SUBJECTS.

Pre-inversion Inversion Inverted Post-inversion

seated 45 sec. 3min. seated
Systolic blood pressures (mm. Hg) 119 ± 2.63 157 ± 4.22* 148 ± 3.70* 123 ± 2.64
Diastolic blood pressures (mm. Hg) 74 ± 1.81 93 ± 1.93* 90 ± 2.11* 75 ± 1.99
*Significantly different (p< .OOl) from both pre-inversion and post-inversion. No differences were found between pre- and post-inversion values.

Effects of gravity inversion procedures 855/113

 35
160

120 30 INTRAOCULAR

~.
"'
r
E
5 eo "'
en
25

~ :r"'
~ E
~
"0
0
0
.,
_§

40
iii .t 20

4 0 2 4
P\'e-inversion Inver sion Period Fbst - inversion Pl'e -inversion Invers ion Period Post- inversion
Measures in Minutes Measured in Minutes

• Significantly hi<jler than prein~on le...els { p<.OOI). No signif icant chaocJes • Significantly higher than preinversion levels (p<.OOI). No significant changes
were found between pre- and post-inversion. were found between pre- and post- inversion.

Fig. 4. Graph depicting the central retinal artery pressure variation with change in posture. Fig. 5. Graph depicting elevation in intra-
ocular pressure with positional changes.
INVER-
TABLE 2. CENTRAL RETINAL SYSTOLIC AND DIASTOLIC PRESSURE AND INTRAOCULAR PRESSURES BEFORE, DURING AND FOLLOWING
SION. VALUES SHOWN ARE MEAN AND STANDARD ERROR FOR 20 SUBJECTS.
Pre-inversion Inverted Post-inversion
seated 3 min. seated

Systolic central retinal pressure (mm. Hg) 45 ± 7.21 105 ± 8.50* 51 ± 8.37
Diastolic central retinal pressure (mm. Hg) 26 ± 4.53 62 ± 7.18* 32 ± 5.46
Intraocular pressure (mm. Hg) 19 ± 0.57 35 ± 1.26* 19" ± 0.95

*Significantly higher than pre-inversion levels (p< .OOl). No significant changes were found between pre- and post-inversion.

tent with our study, and although Katkov's sub- gerous hypertensive episode while inverted.
jects were only -20° inverted, we feel that addi- The observed increases in central retinal arteri-
tional studies w1th longer inversion times would al pressure on inversion are likely related to an in-
be useful in resolving whether adaptation occurs crease in blood volume in the head and neck and to
at -90° inversion. the correlated decrease in venous return from
Thornburg and Lapidies, 11 in their study of ure- those regions. The increases in intraocular pres-
teral peristalsis in eleve~ men placed in a totally sure presumably occurred as a result of an in-
inverted position ( -90°) for 25-35 minutes, report- creased resistance to aqueous outflow from an ele-
ed elevated systolic and diastolic pressures in all vation of episcleral venous pressure similar to that
subjects. Pulse values in this study were found to which occurs when a person changes from the sit-
be elevated in five of their subjects, and decreased ting to the supine position.12 •13
in the other six. It is commonly accepted that in some patients an
We speculate that cerebral artery pressures, increase in intraocular pressure can occur in the
which normally are lower than mean arterial pres- absence of other changes which are seen in severe
sure, would be elevated above MAP in the inverted glaucoma, such as visual field loss and optic nerve
position, and this increase, coupled with the aver- atrophy. These patients may be considered to have
age increase in systolic (30 mm. Hg) and diastolic intraocular hypertension. In our experiments the
(20 mm. Hg) pressures seen in this study, could large elevation in intraocular pressure which oc-
raise cerebral artery pressures to unexpectedly curred with inversion could be considered to be
high levels. Thus, it seems possible that hyperten- equivalent to intraocular hypertension and may
sive patients might experience a potentially dan- put some patients with impaired aqueous outflow

856/114 J uly 1983/J ournal of AOA/vol. 82/no. 11

 at a greater risk of developing visual field loss and
optic nerve atrophy.
It should be noted that our subjects were invert-
ed for only 3 minutes, but many individuals par-
ticipating in this "fad" hang for 10-20 minute per-
iods, with some exercising and lifting weights in
the inverted position.
Conclusion
Because of the significant elevations in systemic
and central retinal arterial blood pressures, pulse
rate , and intraocular pressure reported in these
experiments, it is our recommendat ion that cau-
tion should be observed in the prescription of the
use of inversion boots. Clearly, there is cause for
concern in those individuals with a history of hy-
pertension, cardiovascular disease, and stroke.
We feel that further stl.).dy is necessary to evalu-
ate the risk of patients with spinal fusions of un-
certain stability, weak spinal ligaments/ 4 reflux
esophagitis, or patients on aspirin or platelet in-
hibitors. A general caution must be urged for the
elderly who are already a high risk population for
cerebrovascula r accident. Finally, it would be pru-
dent to have intraocular pressures and visual
fields checked before embarking on an inversion
program.
Appreciation is expressed to Thomas W. Allen, D.O., FA -
COl, Richard Bell, Ph.D., Carol Claycomb, D.O., Arthur
W. Hafner, Ph.D., Alison K. Hubbard, M.A., Robert E.
Kappler, D .O., FAAO, Albert F . Kelso , Ph.D., Amor
Lowsitisukdi, Marc Mayer, D .O., Daniel Richardson,
Ph.D., and Kenneth A. Suarez, Ph.D. , Chicago College of
Osteopathic Medicine, for their assistance.
Effects of gravity inversion procedures
1. Martin , R.M.: The gravity guiding system. Gravity Guidance Inc.,
Pasadena, Calif., 1982
2. Klein , F. C.: On sports. Wall Street J ournal, p. 28, 21 Oct 82
3. Adelson , S.: Robert Martin's boots were made for hanging-and for
overturning back pain. People 18:125-6, Oct 82
4. Hang ten. Flipping over gravity boots. Time, p. 61 , 2 May 83
5. Plocher, D.W.: Inversion petechiae. N Eng! J Med 307:1406-7, 25 Nov
82
6. Back specialists hit "inversion" fad. Medical World News, pp. 49-50 ,
28 Mar83
7. Chusid, J .G.: Correlative neuroanatomy and functional neurology.
Ed. 15. Lange Medical Publications, Los Altos, Calif., 1973
8. Keppel , G.: Design and analysis. A researcher's handbook. Prentice-
Hall , Inc. , Englewood Cliffs, N.J., 1973
9. Berne, R.M., and Levy, M.N.: Cardiovascular physiology. Ed. 4. C.V.
Mosby Co., St. Louis, 1981
10. Katkov, V.E. , eta!. : Central and cerebral hemodynamics and me-
tabolism of the healthy man during head-down tilting. Avi at Space En-
viron Med, pp. 147-53, Feb 79
11. Thornbury, J.R. , and Lapides, J.: Effect of gravity on ureteral peri-
stalsis in normal human adults in the inverted position. J Urol111:465-
7, Apr 74
12. Leith, A.B. : Episcleral venous pressures in tonography. Br J Oph-
thalmol47:271-8, 1963
13. Galin, M.A., Mcivor, J .W., and Magruder, G.B.: Influence of posi-
tion on intraocular pressure. Am J Ophthalmol, pp. 720-3 , 1973
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iotherapy 67:72-3 , Mar 81
Duke-Elder, S.: System of Ophthalmology. C.V. Mosby Co. , St. Louis ,
1968, vol. 4
Accepted for publication in May 1983.
Dr. Klatz is an instructor in the Department of Osteopathic
Medicine at Chicago College of Osteopathic Medicine, Chicago.
Mr. Goldman is a fellow in the Department of Osteopathic
Medicine at CCOM. Dr. Pinchuk is a staff member in the De-
partment of Ophthalmology at CCOM. Dr. Nelson is an assis-
tant professor in the Department of Osteopathic Medicine at
CCOM. Dr. Tarr is a professor in the Department of Physiology
atCCOM.
Dr. Klatz , Chicago College of Osteopathic Medicine , 5200
South Ellis Avenue, Chicago, Illinois 60615.
857/115