Autonomic Function in Paralympic Athletes with Spinal Cord Injury
The missing piece of classification (and why "boosting" is banned)
Key Findings
After a spinal cord injury (SCI) many organs, including the cardiovascular system, cease to be controlled by the autonomic nervous system (ANS); the response to physical activity fails to meet the body's needs and typically results in low blood pressure, and in turn reduced endurance and performance
Athletes with a high-level SCI affecting the ANS have a limited ability to regulate heart rate and blood pressure in response to exercise
Under current Paralympic classification these athletes are grouped with competitors who have similar motor control but an intact ANS — potentially a disadvantage within their own class
High-level SCI athletes with ANS dysfunction are the only athletes who experience autonomic dysreflexia (AD): a state of uninhibited sympathetic discharge. Intentionally induced during competition it is called "boosting"; boosting has been shown to improve sporting performance but can cause serious complications from extreme rises in blood pressure — banned by the International Paralympic Committee (IPC), yet some elite high-level SCI athletes continue to boost
The IPC recognises that the current classification systems are not the gold standard; the authors call for a simple, valid and reliable bedside assessment of autonomic function and for SCI research to group participants by presence/absence of ANS function, not lesion level alone
Not in the abstract (general SCI physiology, not the focus of this review): sweating and skin blood flow are also autonomically controlled, so thermoregulation below the lesion is impaired — heat is a separate risk for these athletes
Practical Application
Review of 60 papers: elite athletes with a high-level SCI and autonomic dysfunction cannot regulate heart rate and blood pressure normally during exercise (low BP → reduced endurance), yet are classified alongside athletes with the same motor level and an intact ANS; "boosting" (self-induced autonomic dysreflexia) improves performance but causes dangerous BP spikes and is banned by the IPC.
Adaptive-sport coach: expect a blunted heart-rate and blood-pressure response with high lesions — HR-based intensity targets and comparisons with able-bodied norms do not transfer; individualise load
Watch blood pressure; never use or condone "boosting" — it is prohibited and dangerous
Classification should account for autonomic function, not only the motor level — an argument this review makes, not a rule in force
Not in the abstract (general SCI physiology): plan cooling for SCI athletes in the heat, because sweating below the lesion is impaired
Limitations
Specific to SCI; other disability categories (amputations, cerebral palsy, vision) have different physiology
A review; classification systems continue to evolve
Overall there are fewer data on adaptive sport than on Olympic sport
How this entry was checked and changed
Content correction 2026-09-27
Entry led with thermoregulation/sweating and external cooling; the abstract is about cardiovascular autonomic control, low BP → reduced endurance, boosting and classification. Lead rewritten to the paper's actual findings; thermoregulation kept only as a labelled "not in the abstract" note.
Added the review's scope (60 manuscripts + 5 website documents) and the IPC ban / continued boosting from the abstract.