Running head: BOOSTING IN PARALYMPIC SPORT

Boosting in Paralympic Sport Makrina Morozowski University of Lethbridge

BOOSTING IN PARALYMPIC SPORT

BOOSTING IN PARALYMPIC SPORT Paralympic sport has developed and grown tremendously over the last 60 years. Different types of sports and disabilities, such as spinal cord injury (SCI), have been

incorporated into paralympic sport. Classifying different disabilities to make competition more equal is a challenging task. Individuals with SCI can present with an inefficient cardiovascular system, have symptoms that lead to an autonomic dysreflexia diagnosis, and voluntarily stimulate ones body, known as boosting, to improve ones athletic ability. The International Paralympic Committee (IPC) bans boosting as it positively impacts athletic performance. Boosting can only be performed in a subset of SCI individuals. Boosting is done in athletes with have a spinal cord injury at or above the Thoracic (T) 6 level (Krassioukov et al., 2005). A stimulus in or to the body below injury level causes autonomic dysreflexia (AD), which primarily elevates blood pressure (Mills & Krassioukov, 2011). AD can occur in individuals with spinal cord injury (SCI) T6 or above. Webborn and Van de Vliet (2012) explain that the stimulus results in a sympathetic discharge and a cardiovascular response that enhances physical performance. An issue arises when AD is intentionally induced, in the athletic world known as boosting, by an athlete, which increases athletic performance. AD can occur in some individuals with SCI and boosting, inflicting AD upon oneself, is used as an ergogenic aid. AD can occur in individuals with a high spinal cord that can impede function. Krassioukov (2009) found a strong correlation between the level of SCI and the severity of autonomic dysfunctions. The higher the injury the increase of likelihood of living with AD and the intenseness of the disorder increases (Krassioukov et al., 2005). AD is caused

BOOSTING IN PARALYMPIC SPORT by abnormal autonomic control and loss of supraspinal input to the spinal sympathetic circuits (Krassioukov, 2009). SCI leads to a loss of tonic inhibition that is present in AD (Krassioukov, 2009). As mentioned earlier, stimuli below the level of injury can cause AD. In an editorial, written by Harris (1994) he explains some of the stimulis that can cause AD. The causes include prolonged skin pressure, pressure ulcers, muscle spasms, skeletal stimulation, anal fissure, cystitis, and stimulation of the penis. Common ways to

induce AD in athletes is increasing fluid intake, over-distending the bladder, sitting on the scrotum, clamping foley catheter, prolonged sitting in racing chair, and breaking their big toe (Mills & Krassioukov, 2011). SCI leads to an interruption of pathways of the autonomic nervous system (ANS) that directly affects the cardiovascular (CV) system (Mills & Krassioukov, 2011). The ANS consists of two parts. Parasympathetic system is the first, which is monitored by the vagus nerve, brings the heart rate down, and is key in restful states. Sympathetic system is the second, which reacts to physiological stress and increases heart rate (HR) and blood pressure (BP) (Mills & Krassioukov, 2011). Krassioukov et al. (2009) has found that the damage to the descending vasomotor pathways results in the loss of inhibitory and excitatory supraspinal input to the sympathetic neurons. This alone has been thought to cause unstable blood pressure that follows SCI (Krassioukov et al., 2009). Boosting occurs when an athlete bothers any part of the body below injury that causes stress and because the person cannot feel it thus increasing both stress and heart rate. As a result from the stress that is put on the body there are negative effects. AD is dangerous for the individual experiencing it and can occur in 90% of individuals with T6 or higher SCI (Krassioukov, 2012). Boosting is induced AD where there is no control to

BOOSTING IN PARALYMPIC SPORT the degree and unpredictable to the amount. Symptoms are variable. Krassioukov et al. (2009) list symptoms that can include feelings of anxiety, goose bumps, intracranial hemorrhage, retinal detachment, seizures, and even death. Blurred vision, bradycardia, cardiac arrhythmias and arterial fibrillation can occur too. In an editorial, written by Harris (1994) additional reactions to boosting include tightness of the chest and hyperthermia. Symptoms that an athlete who is boosting may desire includes increasing levels of peak heart rate, peak blood pressure, increasing amount of circulating norepinephrine levels, and having maximal VO2 and Peak power (Mills & Krassioukov,

2011). Both AD and boosting cause effects to the body that cause negative consequences. Though AD causes negative effects, the act of boosting in athletes can have positive results in terms of competition output. Athletes have reported that high-level injury, above T6, leads to a restricted potential in competition. Cardiac output, maximum oxygen transportation, along with a restricted heart rate and body temperature are some of the negative consequences of SCI that impact physical aspects of sport (Webborn & Van de Vliet, 2012). Athletes primarily boost to enhance performance during practice and competition (Kkrassioukov, 2012). Mills and Krassioukov (2011) report positive side effects in sport performance as a result of boosting. Effects include increased arm strength, increased endurance, decreased arm stiffness, improved breathing, and an increased level of alertness and aggressiveness (Mills & Krassioukov, 2011). Boosting can have negative side effects and consequences. Headaches, excessive shivering, and sweating are some negative effects from boosting (Mills & Krassioukov, 2011). Boosting is primary used by athletes to increase performance abilities.

BOOSTING IN PARALYMPIC SPORT Boosting can only be carried out in a specific population. Only individuals with SCI and those with injury at or above T6 injury can experience AD. Boosting is what athletes who are involved in disabled sport perform to themselves to increase their performance and athletic abilities. Mills and Krassioukov (2011) have found that SCI above T6 levels lead to lower maximal oxygen uptake, lower peak power, and smaller heart volumes. This is a problem when you have both athletes with and without ANS problems competing on the same level. An argument posed by athletes with ANS problems, is they do it because they are at a physical disadvantage. In an editorial, written by Harris (1994) seven out of eight athletes boosted by over distending their bladders. The other athlete sat on his racing chair for a few hours. In a wheelchair racing competition, it was found that athletes, who boosted decreased race time by 9.7%, had increased levels of noradrenalin, and had significantly higher VO2

(+19.8%) rates. During the 2008 Beijing Summer Games, 99 participants were surveyed. It was found that 54.2% of athletes were from wheelchair rugby, 54% were familiar with boosting, and only 10 athletes admitted to engaging in the act (Bhambhani et al., 2010). The performance effects on individuals with a high SCI are noticeable and do impact athletic events. Athletes are classified in certain categories to allow for fair competition. Mills and Krassioukov (2011) explain how The IPC has a structured way of looking at each athlete and placing them into sports classes. Assessment consists of four parts. The first includes medical documentation of impairment. This could come from an athletes personal doctor that specializes in SCI. Following that, a physical examination takes place to determine the severity of the impairment. Next, a technical assessment occurs

BOOSTING IN PARALYMPIC SPORT were the athlete performs sport specific tasks to determine performance ability and the degree of impairment limited by injury or disability. To wrap up the classification assessment, classifiers observe the athlete in a training or competition setting and determine codes in that respect. Each athlete is given a code that is used to factor your time in racing to put all participants on an equal playing level (Krassioukov, 2011). Codes can also be used to ensure different abilities are on the basketball court during a game. In wheelchair basketball, each athlete is coded a score between one and 4.5 all based on trunk, limb, and hand function. A higher impairment results in a lower number. A maximum of 14 points per team is allowed (Krassioukov, 2011), this ensures different

abilities are playing together and that teams are equal in terms of points. Classification is done in paralympic sport to help even out the playing field and put athletes into different categories so competition is both fair and equal. Though the classification system aims to organize competitive athletes in a particular way, the classification system has been debated for a period of time. Classification primarily focuses on impaired motor control and how it affects the athletes ability to perform in sport competition (Mills & Krassioukov, 2011). Mills and Krassioukov (2011) describe that classification leads to fair competition. In contrast, classification does not take into account the effect that high level SCI has on the ANS and the CV system. Boosting does not fall under the specific definition of doping but can be related by the effects that it provides. The IPC defines doping to be The administration of or use of any substances foreign to the athletes body, or of any physiological substance taken in abnormal quantity or taken by abnormal

BOOSTING IN PARALYMPIC SPORT route of entry in to the body with the sole intention of artificially increasing performance in competition. (Mills & Krassioukov, 2011, pp. 773). This definition of what doping is by the IPC can be dissociated and argued in different manners. In no way, shape, or form are athletes administering a foreign substance to the body. What causes AD, is stimuli that the body cannot respond to. A person, who practices boosting cannot take it in abnormal quantities, boosting cannot be measured in quantity and the athlete has little control of the degree or intensity. It is often found by

measuring heart rates. There is no abnormal route of entry. Sitting on a chair, something considered normal, can cause AD to occur. When an athlete boosts, there have been reports that they do it to enhance performance in competition (Krassioukov, 2009). This way of classifying athletes does not take into account CV impairment and though there are many flaws in the definition of doping, boosting is considered unethical and illegal by the IPC Medical Commission (Krassioukov, 2009). Boosting by the definition of doping is not doping, but does impact the bodys performance, like drug doping could do. As boosting is banned by the IPC in paralympic sports strategies including, education, explanation, and changing the classification system can be a few ways to reduce boosting. A recommendation to reduce boosting would include altering the classification system in a way that puts athletes who present with high SCI and AD some sort of compensation in their classification in related to the negative impacts AD has on a persons CV system (Mills & Krassioukov, 2011). Strategies have been implemented to decrease the prevalence rates of boosting in the past. Athletes were screened in the 1996 Atlanta Summer Paralympic Games by taking the athletes blood pressure and looking for other symptoms of AD or boosting. Medical staff would take blood pressure and if it was

BOOSTING IN PARALYMPIC SPORT above 180mmHg the athlete was given time to rest, fix it, then re-measured (Mills & Krassioukov, 2011). Another recommendation could include talking to individuals and athletes who have SCI, none of them had an injury high enough to have AD be an issue, but none of them knew what AD was, what causes it, and that it is illegal to try to improve sport performance. Educating populations that are at risk for developing boosting behaviors

would be a good start. They could implement it as part of the recovery process after SCI. Research should continue in finding different ways to prevent AD, which would lead to a prevention of boosting. Athletes with a higher SCI can present with AD, which if induced, can cause boosting, with increases sport performance. The hallmark symptom of boosting is an increase in heart rate, though there are other symptoms unique to both AD and boosting. The IPC has aimed to classify athletes of different disabilities in a fair way to ensure an equal and fair competition. The classification system does not consider the implications that SCI place on the cardiovascular system and make it incredibly difficult to reach the abilities of their fellow competitors. In the future, hopefully the classification system may consider the secondary affects of disabilities like SCI other than the primary ones like paralysis.

BOOSTING IN PARALYMPIC SPORT References Bhambhani, Y., Mactavish, J., Warren, S., Thompson, W, T., Webber, A., Bressan, E., Vanlandewijck, Y. (2010). Boosting in athletes with high-level spinal cord injury: Knowledge, incidence and attitudes of athletes in Paralympic sport. Disability and Rehabilitation 32(26), 2172-2190. doi: 10.3109/09638288.2010.505678 Editorial: Self-induced autonomic dysreflexia (boosting) practiced by some tetraplegic athletes to enhance their athletic performance [Editorial]. (1994). International Medical Society of Paraplegia, 13, 289-291. Klenck, C., & Gebke, K. (2007). Practical Management: Common medical problems in disabled athletes. Clinical Journal of Sport Medicine, 17 (1), 55-60. Krassioukov, A. (2012). Autonomic dysreflexia: Current evidence related to unstable arterial blood pressure control among athletes with spinal cord injury. Clinical Journal of Sports Medicine, 22(1), 39-45. Krassioukov, A. (2009). Autonomic function following cervical spinal injury. Respiratory Physiology & Neurobiology, 169, 157-164. doi: 10.1016/j.resp.2009.08.003 Krassioukov, A., Warburton, D, E., Teasell, R., Eng, J, J., et al. (2009). A systematic review of the management of autonomic dysreflexia after spinal cord injury. American Congress of Rehabilitation Medicine, 90, 682- 695. doi: 10.1016/j.apmr.2008.10.017

BOOSTING IN PARALYMPIC SPORT Lertwanich, P. (2009). The disabled athlete and related medical conditions. Siriraj Medical Journal, 61(2), 100-103. Retrieved from: http://www.sirirajmedj.com/content.php?content_id=2417 Mills, P, B., & Krassioukov, A. (2011). Autonomic function as a missing piece of the

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classification of Paralympic athletes with spinal cord injury. Spinal Cord, 49, 768776. doi: 10.1038/sc.2011.2 Slater, D., & Mead, M, A. (2004). Participation in recreation and sports for persons with spinal cord injury: Review and recommendations. NeuroRehabilitiation, 19, 121129. Webborn, N., & Van de Vliet, P. (2012). Paralympic Medicine. The Lancet, 380, 65-71. Retrieved from: http://press.thelancet.com/sport2.pdf