Infographic. Doping without drugs: how para-athletes may self-harm to boost performance

This infographic provides a summary of the use of boosting by athletes with spinal cord injury (SCI); its causes, warning signs and dangers, and the current approach of the International Paralympic Committee (IPC) to testing. Boosting is the intentional induction of autonomic dysreflexia (AD) to enhance performance. AD is a potentially life-threatening condition experienced by many individuals with a SCI, typically at or above the T6 spinal level. It is characterised by a sudden increase in systolic blood pressure (SBP) >20 mm Hg above baseline due to a noxious or non-noxious stimuli below the level of injury, that excites sympathetic preganglionic neurons resulting in vasoconstriction of blood vessels in the lower extremities and trunk.1 Triggers include, but are not limited to, bladder distension, injury or an innocuous stimulus (eg, a tight shoelace or belt) below the level of injury. Without prompt resolution, severe cases of AD may result in cerebral haemorrhage, myocardial ischaemia, seizures, arrhythmias or death.2 While prolonged hypertensive crises are rare in athletes, repetitive asymptomatic AD events present a substantial long-term health consequence and may partially explain the heighted cardiovascular mortality risk in individuals with SCI.