Introduction and Purpose
Individuals with spinal cord injuries at or above the sixth thoracic vertebra level (T6 level) can spontaneously experience autonomic dysreflexia. Besides eliciting symptoms such as headache, nausea, dizziness, and blurred vision, it can also induce a significant increase in blood pressure, thereby placing the individual at an increased risk for cerebrovascular and cardiovascular events. Athletes with spinal cord injuries can voluntarily induce autonomic dysreflexia prior to or during the event in order to enhance their performance. The nociceptive stimuli commonly used to induce this reflex are:
(i) over-distending the bladder,
(ii) sitting on sharp objects, and
(iii) use of tight leg straps.
This procedure, which is commonly referred to as ‘boosting’, is usually done one or two hours before the actual event for the reflex to be fully effective. It is postulated that the elevated blood pressure in the dysreflexic condition enhances the cardiovascular and hormonal responses, thereby improving performance. The World Anti-Doping Agency (WADA) defines doping as any technique that improves performance either by ingesting an external substance or by a method which offers undue advantage. In 1994, the International Paralympic Committee (IPC) deemed boosting to be illegal and banned its practice during competition because research had demonstrated that it was a method that significantly improved performance. Their primary concern was the health and safety of the athlete. Currently, there is no research that has systematically examined the incidence, knowledge and attitudes of competitive athletes pertaining to boosting.
The objectives of this research study were to:
(1) examine the incidence of boosting in competitive high level spinal cord injured athletes,
(2) evaluate their knowledge and beliefs with respect to the effects of boosting on sport performance and overall health, and
(3) document their attitudes towards boosting and other performance enhancement strategies in competitive sport.
Research Design
This research study was implemented in four phases. In Phase I, a comprehensive boosting questionnaire designed to evaluate the incidence, knowledge and beliefs, and attitudes towards boosting was developed and validated by the International Paralympic Committee Sport Science Committee (IPCSSC), in conjunction with experts in the field of questionnaire design. In Phase II, a pilot study was conducted to evaluate the questionnaire for content and readability in 15competitive spinal cord injured athletes. In Phase III, data were collected in three ways: (i) an online version of the questionnaire was posted on the IPC website so that athletes could complete this at their convenience; (ii) the questionnaire was sent to members of the International Network for the Advancement of Paralympic Sports through Science (INAPSS) for distribution to eligible athletes, and (iii) during the Paralympic Games in Beijing from 6th to 17th September 2008. In Phase IV, the data were statistically analyzed using the Fisher Exact test to obtain information pertaining to specific questions on the incidence, knowledge and beliefs, and attitudes toward boosting.
Participants
A total of 99 participants completed the questionnaire. Of these 84 were males, 11 were females, and four participants did not identify their gender. In both genders, majority of the participants were in the 34 to 39 year age group (31. 3%), followed by the 28 to 33 yr (23.3%), 16 to 21 yr (20.1%) and 40 to 45 yr (12.1%) age groups. The education level varied considerably amongst the participants. The younger participants had completed some high school education while many of the older ones had attained university undergraduate and post graduate degrees. The injury duration also varied considerably amongst participants and ranged from 1 year to 18 years. A large majority of the participants were involved in wheelchair rugby (54.2%), followed by wheelchair sprint events (10.4%), middle distance racing events and wheelchair basketball (9.4% each), marathon racing, long distance events and throwing events (6.3% each).
Awareness and Incidence of Boosting
Of the 99 participants who completed the survey, 54 (54.5%) had heard of boosting prior to reading about it in the questionnaire, while 39 (39.4%) had not heard of boosting previously. The remaining participants were either unsure (3 or 3%) or did not respond to this question (3 or 3%). There were a significantly greater number of males who had prior knowledge of boosting compared to females. The participants were specifically asked the question: “Have you ever intentionally induced autonomic dysreflexia to boost your performance in training or competition?” Of the 60 participants who responded, 10 (16.7%) responded affirmatively while 50 (83.3%) responded negatively. All the positive responses were obtained from the male participants, with the majority competing in wheelchair rugby (55.5%), followed by wheelchair marathon (22.2%) and long distance racing (22.2%). None of the participants involved in wheelchair basketball and throwing events used boosting to enhance performance in training or competition. Approximately two thirdsof those who boosted reported that they had never used it: (1) during regular training (64.7%), (2) while training to peak for competition (66%), (3) in national competitions (64%), and (4) in international competitions (62%). A small proportion (6% to 14%) of respondents used it during the two training phases or competitions identified above. Only one participant (2%) indicated that he used boosting all the time during national and international competitions to improve performance.
Knowledge and Beliefs about Boosting
Approximately 41% of the participants felt that boosting was more useful in some sports compared to others, while 15% indicated the opposite. The remaining 44% of the participants were unsure whether boosting was more useful in some sports compared to others. Majority of the participants reported that boosting was most useful in middle distance events (78.6%), long distance events (71.4%), marathon racing (64.3%) and wheelchair rugby (64.3%). This was followed by sprint racing events (57.1%), wheelchair basketball (32.1%), Nordic skiing (21.4%), alpine skiing (10.7%), field throwing (10.7%) and other events (3.6%). Majority of the participants indicated that boosting was most useful during competition (80.5%) when compared to the other phases such as during training (9.8%) or immediately prior to competition (7.3%). The participants identified the following variables that they felt benefited most from boosting during competition: increased arm strength and endurance, less arm stiffness, less difficulty breathing, improved circulation, less overall fatigue, increased aggression, and increased alertness. However, a small number of participants also reported increased anxiety and greater frustration as possible effects of boosting during competition. Most of the participants agreed that boosting was somewhat dangerous (48.9%) to health. However, 21.3% and 25.5% of the respondents also felt that boosting was dangerous or very dangerous to health respectively. Only a small proportion (4%) of the respondents said that boosting was not at all dangerous. With respect to the symptoms of boosting, most of the respondents identified headache (70.9%), excessive sweating (80.6%), and high blood pressure (83.3%) as the most frequent ones. Shivering (36.8%) and blurred vision (26%) were less frequently reported by the participants. The main source of knowledge regarding the symptoms of boosting was their personal experience (61.7%) and reports from other athletes (50%). The participants gained some information by reading about boosting (22.9%) and received only minimal information (2.1 %) from their coaches. When queried about the consequences of boosting, most of the subjects identified high blood pressure (86%), stroke/cerebral hemorrhage (59.6%), and death (44%) aspossible outcomes. Only a small proportion (16.1%) identified seizures as being a possible consequence of boosting.
Attitude towards Boosting
Majority of the participants indicated that boosting was “completely unacceptable” for improving training capacity (61.3%), maximizing performance in competition (64.5%), because of knowledge of other competitors were boosting (57.4%), or boosting itself (60.3 %). When queried whether “boosting should not be banned because it can happen unintentionally” their opinion was split. Approximately 25% of the participants found this unacceptable while 37% were in agreement with the statement. Similarly, the participants expressed opposing views in responding to the statement “boosting should not be banned because any athlete with T6 or higher spinal cord injury can decide to induce autonomic dysreflexia.” Approximately 50% of the participants indicated that they currently used other methods to improve performance in training and/or competition which had no associated health risks. Almost 100% of the participants reported that using banned drugs to improve training capacity and maximize performance was unacceptable. These participants also indicated that using banned drugs because their competitors were using them was unacceptable. In responding to the general question “whether doping was a concern in Paralympic sports,” 50% of the participants indicated that it was sometimes a concern. This suggests that the decision to boost or no to boost in or order to enhance performance during training and/or competition is an individual one. Generally speaking, the incidence, knowledge and beliefs, and attitude towards boosting were not influenced by:(1) age, (2) injury level, and (3) injury duration of the participants. However, there was a tendency for the incidence of boosting to be higher in participants with postgraduate degrees compared to those with some high school or post secondary education. These findings should be interpreted with caution due to: (1) the small sample size, particularly in the females, (2) participation primarily from athletes in English speaking countries, and (3) use of selfreport questionnaires.
Recommendations
Bearing in mind the study limitations, it is recommended that: (1) educational materials pertaining to boosting be developed in conventional and electronic media to educate the athletes, coaches and trainers about this banned doping method, (2) a concerted effort should be made to target geographical regions where the awareness of boosting is likely to be low and sports in which the likelihood of boosting is high, (3) the frequency of boosting tests at the Paralympic games and other IPC sanctioned events be increased considerably so that the trends in this method of coping can be systematically evaluated, and (4) further research be conducted on a larger number of male and female Paralympic athletes with high level spinal cord injuries in order to increase the generalizability of the study findings.
