RESEARCH PAPER

Boosting in athletes with high-level spinal cord injury: knowledge,incidence and attitudes of athletes in paralympic sport

YAGESH BHAMBHANI1, JENNIFER MACTAVISH2, SHARON WARREN1,

WALTER R. THOMPSON3, ANTHONY WEBBORN4, ELIZABETH BRESSAN5,

MARCO TUILO DE MELLO6, SEAN TWEEDY7, LAURIE MALONE8, KENNET FROJD9,

PETER VAN DE VLIET10 & YVES VANLANDEWIJCK11

1Faculty of Rehabilitation Medicine, University of Alberta, Canada, 2Faculty of Kinesiology and Recreation Management,

University of Manitoba, Canada, 3Department of Kinesiology and Health, Georgia State University, Atlanta, Georgia, USA,4Sussex Centre for Sport and Exercise Medicine, Chelsea School Research Centre, University of Brighton, UK, 5Department of

Sport Science, Stellenbosch University, South Africa, 6Medicina e Biologia do Sono, Universidade Federal de Sao Paulo,

Brazil, 7School of Human Movement Studies, University of Queensland, Brisbane, Australia, 8Lakeshore Foundation,

Research and Education, Birmingham, Alabama, USA, 9Swedish Development Centre for Disability and Sport and University

of Gavle, Sweden, 10Medical and Scientific Director, International Paralympic Committee, Bonn, Germany, and 11Faculty of

Kinesiology and Rehabilitation Sciences, Catholique University, Leuven, Belgium

Accepted June 2010

AbstractAutonomic dysreflexia (AD) is unique to individuals with spinal injuries (SCI) at T6 or above and can be voluntarily induced.Although AD improves wheelchair racing performance in some athletes, it also elicits exaggerated blood pressure, whichcould be dangerous. The International Paralympic Committee considers AD doping and banned its use. Purpose. The purposeof this study is to evaluate AD knowledge, incidence and attitudes (KIA) of Paralympians with SCI. Methods. An existingquestionnaire was modified to include questions of AD KIA, validated by three experts and piloted with a small sample. It wasadministered on-line, mailed to members of a scientific network and distributed during the Beijing Paralympic Games. FisherExact test was used to evaluate differences across gender, injury and education. Results. Of 99 participants, 54.5% hadpreviously heard of AD while 39.4% were unaware; 16.7%, all males, had used AD to enhance performance. Participantsreported that AD was (1) useful for middle (78.6%) and long distance (71.4%), marathon (64.3%) and wheelchair rugby(64.3%); (2) somewhat dangerous (48.9%), dangerous (21.3%) or very dangerous (25.5%) to health. Results were notinfluenced by age, injury level or injury duration. Conclusions. Findings indicate the need for educational programmes directedtowards enhancing the AD knowledge of rehabilitation professionals, coaches and trainers working with SCI individuals.

Keywords: Boosting survey, paralympic athletes

Introduction

There is no less contentious issue in elite sport than

doping to enhance performance. Athletes are always

looking to find the edge over opponents by fair

means, or by foul in some cases. Potentially

hazardous risks to health through doping are taken

in the pursuit of sporting excellence. The increasing

profile of sport for athletes with a disability and its

potential rewards combined with the frailty of human

nature has led some athletes with disabilities to seek

improved performance through the administration of

prohibited substances. However, there is a method

unique to sport for athletes with a disability, which is

termed ‘boosting’ for the intentional induction of

autonomic dysreflexia (AD) to enhance performance

[1–3]. This was deemed a prohibited method by the

International Paralympic Committee (IPC) in 1994

[4], but this was later changed to being classed as a

health risk and prohibits athletes from competing in a

Correspondence: Yagesh Bhambhani, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada T6G 2G4.

Tel: þ780-492-7248. E-mail: yagesh.bhambhani@ualberta.ca

Disability and Rehabilitation, 2010; 32(26): 2172–2190

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2010 Informa UK, Ltd.

DOI: 10.3109/09638288.2010.505678

dysreflexia state whether intentional or not. This is

akin to the use of placing limits on haematocrit levels

in competitive skiing.

The athlete with a high-level spinal injury has

limited physiological potential for improvements in

cardiac output and maximal oxygen uptake, which

are known to improve racing performance. The loss

of sympathetic cardiac innervation results in a

maximum heart rate between 110 and 130 beats

per minute determined by intrinsic sino-atrial activity

[5–7]. The restricted heart rate reserve and reduced

stroke volume are further compounded by a loss of

catecholamine response to exercise and by the

absence of the muscular venous pump in the lower

limbs. These physiological limitations lead some

athletes with high-level spinal cord injuries to partly

compensate for the loss by the induction of the

dysreflexic state. During training and competition,

some athletes had noticed that the dysreflexic state

actually reduced the rating of perceived exertion and

faster top velocities were attained. Although initially

the phenomenon was occurring spontaneously, it

was found that the condition could be voluntarily

induced by practices including clamping of the

urinary catheter to produce bladder distension,

excessive tightening of the leg straps, twisting and/

or sitting on the scrotum. Athletes felt that in this

way they could induce the boosted state on

command [3].

A boosting study [1] conducted on eight wheel-

chair athletes during simulated racing confirmed

significant performance enhancement with the most

striking change being a 9.7% improvement in 7.5 K

race performance time. This would be approximately

equivalent to reducing the able-bodied marathon

record by 12 min! In the boosted state at rest, there

was a lower heart rate; and during exercise, subjects

were able to achieve levels in excess of the normal

maximum. Significant rises in noradrenaline levels

were seen, but no change in adrenaline levels

occurred. However, blood pressure increased to a

significantly higher level in the boosted compared to

the unboosted state and in some cases rose to

dangerously high levels.

The IPC, having determined boosting to be a

prohibited method, have a practical problem with

enforcement. Although the concern is for the safety

of athletes, there are comparisons with growth

hormone abuse – unless you catch the athlete in

the act, how do you detect it? AD occurs sponta-

neously in athletes with high-level spinal cord

injuries, and so to prohibit its use it is necessary that

there be a method of not only detecting an athlete in

a dysreflexic state, but also proving that the state was

intentionally induced. Blood pressure measurements

were made in the call-up room at the 1996 Atlanta

Paralympics and other major sanctioned events, and

the potential threat was to withdraw athletes with

abnormally high readings. The ‘normal value’ of

blood pressure in a call-up room before a Paralympic

final event is difficult to predict. For the sports

physician, coaches and trainers working with athletes

with this disability it is important to be aware of this

condition, whether intentionally induced or not [8].

The immediate management is to remove the

nociceptive stimulus where possible and to admin-

ister sublingual nifedipine to reduce the blood

pressure. The IPC has a fiduciary responsibility to

ensure that athletes compete in a safe manner at the

events that are sanctioned by the organisation [9].

Therefore, it was imperative that a study which

addresses these issues be conducted, so that the IPC

can implement policies that are conducive to their

mission and to protect the athletes.

The World Anti Doping Agency (WADA) Social

Sciences Research Grant Programme has identified

‘increasing knowledge of causes and of risk and

protective factors in doping behaviour’ as one of its

research priorities. To date, there is no published

information pertaining to the knowledge, incidence

and attitudes of paralympic athletes regarding

boosting (i.e. voluntary induction of AD). Therefore,

the current research project was designed to (1)

develop and validate a comprehensive boosting

questionnaire to provide such information, and (2)

evaluate these aspects of boosting in male and female

paralympic wheelchair athletes with spinal cord

injuries at or above the T6 level. This study tested

the following hypotheses: (1) a significant proportion

of the wheelchair athletes with spinal cord lesion

levels above T6 will indicate that they used boosting

to enhance their physical performance during train-

ing and/or competition, (2) there would be no

significant difference between males and females in

the prior knowledge and incidence of boosting, (3)

boosting knowledge would not be influenced by the

education level and injury duration of the athletes,

(4) athletes of both genders would demonstrate

awareness of the signs and symptoms regarding

boosting and (5) a majority of the athletes would find

boosting to be unacceptable for improving perfor-

mance during training and/or competition.

Methods

This study was implemented over a 2-year (yr)

period from March 2007 to February 2009. In

accordance with the Declaration of Helsinki, ethics

approval was obtained from the Health Research

Ethics Board at the University of Alberta prior to

initiating the study. The research design used to

complete this study is illustrated in Figure 1.

Boosting in paralympic athletes 2173

Phase I – validation

During this 9-month phase (March to December

2007), the boosting questionnaire originally published

by Burnham et al. [1] was used as a starting point for

developing a comprehensive questionnaire to evaluate

the knowledge, incidence and attitudes of athletes

towards boosting. Several questions related to these

three themes were added to the questionnaire and

subsequently validated by experts in the area of

questionnaire design. Initially, the questionnaire was

reviewed by two experts in survey research from the

University of Alberta, Edmonton, Canada. Their

recommendations were incorporated into the ques-

tionnaire, which was then reviewed by an expert from

the University of Manitoba, Winnipeg, Canada.

Following these revisions, the modified questionnaire

was sent to the IPC Sports Science Committee (IPC

SSC) for a final review before its implementation. The

validated questionnaire is included in the Appendix.

Phase II – pilot study

A pilot study, which was designed to test the content

and readability of the validated questionnaire, was

conducted from January to March 2008. Fifteen

competitive athletes were contacted through the

International Network for the Advancement of

Paralympic Sport through Science (INAPSS). Ath-

letes from Australia (3), Belgium (2), Brazil (4),

Sweden (2), South Africa (2) and the United States

(2) received the questionnaire from their sports

administrators. These questionnaires were com-

pleted by the athletes and forwarded to the IPC

head office in Bonn, Germany or directly to the

principal investigator at the University of Alberta.

The athletes were asked to comment on the content

and readability of the questionnaire. Their feedback

was used to make final changes to the questionnaire

before its actual implementation.

Phase III - data collection

Data collection was initiated in three ways: (1) an on-

line version of the questionnaire, which was developed

at the end of the validation phase, was posted on the

IPC web site so that athletes could complete it at their

convenience. The on-line questionnaire was available

from August through October 2008. (2) The validated

questionnaire was sent to members of INAPSS for

distribution, and upon completion returned to the

IPC headquarters. (3) Data were collected during the

Paralympic Games in Beijing from 7 to 17 September

2008. This latter process included a number of steps.

First, managers and team physicians of the National

Paralympic Committees (NPCs) who attended the

Paralympic Games were informed of the study at an

orientation meeting one day before the Games

commenced. A covering letter from the Chairperson

of the IPC SSC and the study principal investigator,

along with sufficient copies of the questionnaire, were

subsequently placed in their individual mail boxes for

distribution to the spinal cord injured athletes who met

the inclusion criteria of the study. This letter clearly

specified that only athletes with spinal cord injuries at

or above the T6 level were eligible to participate in the

study. A written reminder was sent to the NPC

managers during the Paralympic Games to encourage

their athletes to complete the questionnaire. As well, a

final reminder was sent to the NPC managers after the

conclusion of the Games, requesting them to remind

the athletes to complete the on-line version of the

questionnaire if they did not have the opportunity of

completing it during the Games in Beijing. Second,

appropriate signage was placed at strategic locations in

the Paralympic Village to inform athletes about the

Figure 1. Experimental design of the study.

2174 Y. Bhambhani et al.

study and seek their participation. Third, members of

the investigative team also personally contacted team

managers and coaches at the various practice venues to

increase athlete participation. Finally, members of the

investigative team telephoned the Operations Man-

agers of the NPCs periodically asking them to remind

the athletes to complete the questionnaires. The

completed questionnaires were returned by the

athletes to the IPC SSC office at the Paralympic

Village either directly or via their NPC managers to

ensure anonymity.

Phase IV – data analysis

A total of 99 participants completed the survey that

was used for data analysis. Following is the break-

down of the completed questionnaires that were used

for analysis: 15 from the pilot study, 34 from the

INAPSS network, 46 completed at the Beijing

Paralympic Games and four completed online. Some

of the participants did not respond to all the questions

in the survey, and therefore, the analysis to the

pertinent questions is based on varying number of

responses. The information from these 99 partici-

pants who completed the questionnaire (hereafter

referred to as respondents) was entered into Survey

Monkey (www.surveymonkey.com), which is a soft-

ware programme used for processing questionnaire

data. The data were then exported into SPSS to

perform the Fisher Exact test to compare the

frequencies of the responses with respect to the

following variables: (1) gender, (2) level of education,

(3) duration of injury and (4) sport participation. This

statistical technique has been designed specifically for

the analysis of contingency tables of categorical data

where the sample sizes are small and/or when there

are fewer than five subjects per cell (Fisher 1970).

The test produces an exact probability but a was set at

0.05. Caution needs to be applied in interpretation of

the results even though this test was used because in

many instances cell sizes were small and often zero.

Consequently trends in the descriptive characteristics

have been reported where pertinent.

Results

Characteristics of participants

Personal characteristics (Questions 19–21). A descrip-

tive overview of the 99 participants who completed

Table I. Characteristics of male and female participants.

Group* Variable Number of participants in each category

Males Age group 16–21 22–27 28–33 34–39 40–45 46þN¼85 4 17 21 26 12 5

Status S-PT S-FT A-PT A-FT A-SF A-SG/OF

N¼72 6 3 9 9 21 17/7

Employment PE-PT PE-FT SE-PT SE-FT UE-LW UE-NLW

N¼60 15 13 8 10 4 10

Education SHS HSG SPS SU UD GD

N¼83 15 25 10 10 10 13

Females Age group 16–21 22–27 28–33 34–39 40–45 46þN¼11 1 2 1 4 0 3

Status S-PT S-FT A-PT A-FT A-SF A-SG/OF

N¼15 0 2 0 2 3 2/6

Employment PE-PT PE-FT SE-PT SE-FT UE-LW UE-NLW

N¼5 2 1 1 1 0 0

Education SHS HSG SPS SU UD GD

N¼10 1 2 1 0 3 3

Combined Age group 16–21 22–27 28–33 34–39 40–45 46þN¼99 5 20 23 31 12 8

Status S-PT S-FT A-PT A-FT A-SF A-SG/OF

N¼90 6 5 9 13 24 20/13

N¼65 Employment PE-PT PE-FT SE-PT SE-FT UE-LW UE-NLW

17 14 9 11 4 10

N¼96 Education SHS HSG SPS SU UD GD

17 28 11 10 13 17

N, number of participants who responded to that question; S-PT, student part time; S-FT, student full time; A-PT, athlete part time; A-FT,

athlete full time; A-SF, athlete self funded; A-SGOF, athlete state/government/other funding; PE-PT, paid employee, part time; PE-FT,

paid employee, full time; A-PT, athlete, part time; A-FT, athlete, full time; A-SF, athlete, self funded; A-SG/OF, athlete, state funded/other

source; SHS, some high school; HSG, high school graduation; SPS, some post secondary education; SU, some university (no degree); ED,

undergraduate degree; GD, graduate degree.

*Three participants did not indicate their gender on the questionnaire (Question #25).

Boosting in paralympic athletes 2175

the Boosting Questionnaire is summarised in Table

I. Three participants did not indicate their sex. Of

the remaining 96 participants, 85 (88.4%) were

males and 11 (11.6%) were females. Independent of

sex, the majority of the participants were in the 34- to

39-yr age group (31.3%), followed by the 28- to 33-

yr (23.3%) age group, 16- to 21-yr (20.1%) age

group and 40- to 45-yr (12.1%) age group. A

considerable variation was observed in the educa-

tional level of the participants. Seventeen percent of

them had some high school education, while 28% of

them had completed their high school diploma.

Twenty-one percent of the participants had enrolled

in post-secondary institutions but had not completed

their undergraduate degrees. However, 13% of them

had undergraduate degrees while 17% completed

graduate degrees.

Spinal cord injury lesions (Questions 22, 23 and 25).

Details of the spinal cord injury of the study

participants are provided in Table II. Of the 99

participants in this study, 95% were aware of their

specific lesion level while 5% were not. Those who

were aware indicated lesion levels ranging from

C5-C7 (high-level tetraplegia) to T6 (high-level

paraplegia). Of these, 44.6% had a complete spinal

cord injury while 44.4% had an incomplete injury.

The remainder (11%) did not provide this in-

formation. There was a large variation in the time

since injury among the participants. In the com-

bined group, 11 participants (12.1%) had a spinal

cord injury for 1–5 yrs, 18 (19.7%) were injured

for 6–10 yrs, 22 (24.17%) were injured for 11–15

yrs and 40 (44%) were injured for 16 or more yrs.

Approximately two-thirds of the participants (61 of

92 respondents) indicated that they had sponta-

neously experienced AD, while 25 had not

experienced it. Six of the participants (6.5%) did

not know whether they spontaneously experienced

AD and three participants did not respond to the

question.

Sport participation (Question 24)

In the overall sample, a majority of the participants

(54.2%) were involved in wheelchair rugby. This

was followed by wheelchair sprint events (10.4%),

wheelchair basketball and middle distance events

(9.4% each), marathon racing, long distance racing

and throwing events (6.3% each). Participants

indicated that they competed in other events not

indicated on the questionnaire 20.8% of the time.

With respect to the two winter sports listed in the

questionnaire, two participants (2.1%) identified

Nordic skiing and none of them identified alpine

skiing.

Awareness of boosting (Question 1)

Of the 93 participants who responded to this

question, 52 (55.9%) had heard of boosting prior

to reading about it in the questionnaire. Among the

remaining 41 participants, 38 (40.9%) had not heard

of boosting previously and three (3.1%) participants

were unsure. The frequency of males who had prior

knowledge of boosting was significantly greater than

that of females (Fisher’s Exact (2, N¼ 93),

p¼ 0.016).

Incidence of boosting (Questions 3 and 4)

When the participants were queried whether they

were able to experience AD spontaneously based on

their injury level (Question 3a), 43 of the 54

respondents answered positively while 11 (20.4%)

answered negatively. However, when the participants

were asked whether they had intentionally induced

AD (i.e. boosted themselves, Question 3b), 10

(16.7%) of the 60 respondents responded positively

while 50 (83.3%) responded negatively. Nine of

these respondents, all males, indicated that they had

used boosting during competition and/or training.

All these respondents had previously experienced

AD spontaneously. The statistical analysis revealed

that males were more likely to use boosting than

females; this difference was statistically significant

(Fisher’s Exact (1, N¼ 58), p¼ 0.000). Among the

respondents who used boosting to improve perfor-

mance in training and/or competition, the incidence

was highest in wheelchair rugby players (five

respondents, 55.5%) followed by those participating

in wheelchair athletics, namely, marathon racing

(two respondents, 22.2%) and long distance racing

Table II. Injury details of participants.*

Group* Variable High Mid Low

Males Injury level C5-C7 T1-T3 T4-T6

N¼79 65 3 11

Duration, years 1–5 6–10 11–15 16þ11 18 17 33

Females Injury level C6-C7 T1-T3 T4-T6

N¼8 5 0 3

Duration, years 1–5 6–10 11–15 16þ0 0 2 6

Combined Injury level C5-C7 T1-T3 T4-T6

N¼87 70 3 14

Duration, years 1–5 6–10 11–15 16þ11 18 19 39

*Note: 12 participants did not answer this question.

2176 Y. Bhambhani et al.

(2 respondents, 22.2%). None of the respondents

involved in wheelchair basketball and throwing

events used boosting to enhance performance in

training or competition. The statistical analysis

revealed that there was no significant difference in

the incidence of boosting across sports (Fisher’s

Exact (4, N¼ 48), p¼ 0.506). Seven of the 10

athletes who used boosting indicated that they did

not use it during regular training, while training to

peak for competition, and in both national and

international competitions. Two of these athletes

used boosting during the training phases and

competitions identified earlier, while on athlete

reported using boosting all the time to improve

performance during national and international com-

petitions.

A comparison of the incidence of boosting across

age, education level and injury level of the respon-

dents is provided in Table III. The younger subjects

aged between 16 and 27 yrs and the oldest subjects

aged above 46 yrs had never voluntarily used

boosting to enhance their performance in training

and/or competition. However, 12.5, 15.8 and 33.3%

of the respondents aged between 28 and 33, 34–39

and 40–45 yrs, respectively, used boosting to

improve their performance in training and/or com-

petition. The statistical analysis indicated that there

was no significant difference in the incidence of

boosting among age categories (Fisher’s Exact (4,

N¼ 59), p¼ 0.339).

Most of the subjects surveyed, regardless of the

level of education, had not voluntarily used boosting

to enhance their performance in training and/or

competition. Of these 48 respondents, eight indi-

cated that they had used boosting to enhance training

and/or competition. Three respondents (37.5%) had

some postsecondary education, one (12.5%) had

some university education and four (50%) had

graduate degrees. The statistical analysis revealed

that as the educational level increased the frequency

of boosting increased (Fisher’s Exact (4, N¼ 48),

p¼ 0.033). Although the incidence of boosting

appeared to be higher in respondents with cervical

injuries (C5 to C7), when compared to respondents

with injuries at the thoracic level (T1 to T3 and T4 to

T6 collapsed), the statistical analysis revealed that

there was no significant difference in the incidence of

boosting by level of injury (Fisher’s Exact (2,

N¼ 55), p¼ 0.370).

Knowledge and use of boosting

A comparison of knowledge of boosting across

education level and injury duration of the respon-

dents is provided in Table IV. The descriptive

statistics showed that respondents who had gradu-

ated from high school were less likely (44%) to have

previously heard of boosting compared to those who

had some post-secondary education (54.5%), some

university education (60%), an undergraduate de-

gree (61.5%) and a graduate university degree

(64.7%). However, the statistical analysis revealed

that there was no significant difference in their

previous knowledge about boosting by level of

education (Fisher’s Exact (8, N¼ 76), p¼ 0.717).

The percentages of respondents who had previous

knowledge of boosting as a performance enhancing

strategy were 27.3, 55.6, 63.2 and 65% in the 1–5, 6–

10, 11–15 and 416 yrs post-injury duration,

respectively. There was no significant difference in

previous knowledge about boosting by duration of

injury (Fisher’s Exact (6, N¼ 88), p¼ 0.12), but

there was a trend towards greater knowledge of

boosting 6 yrs post injury.

With respect to the use of boosting in their sport,

approximately 27.1% of the respondents reported

that boosting was commonly used in their sport while

35.4% were not sure about its use. The results in

Table V indicated that there was no significant

Table III. Incidence of boosting in athletes with high level spinal injury: influence of age, education and injury levels (responses to Question

3b, Appendix A).

Variable

Question 3b: Have you ever intentionally induced autonomic dysreflexia during training or competition to improve your

performance?

Age 22–27 years 28–33 years 34–39 years 40–45 years 46þ years Total Per cent Fisher Exact

Yes 0 2 3 4 0 9 15.3 p¼0.339

No 8 14 16 8 5 51 84.7

Education level HSG SPS SU UD GD Total Per cent Fisher Exact

Yes 0 3 1 0 4 8 16.7 p¼0.033

No 15 5 4 7 9 40 83.3

Injury level High: C5-C7 Mid: T1-T3 Low: T4-T6 Total Per cent Fisher Exact

Yes 8 1 1 10 18.2 p¼0.370

No 33 1 11 45 81.8

SHS, some high school; HSG, high school graduation; SPS, some post-secondary education; SU, some university (no degree); ED,

undergraduate degree; GD, graduate degree.

Boosting in paralympic athletes 2177

difference on knowledge about boosting in their

sport by educational level (Fisher’s Exact (16,

N¼ 48), p¼ 0.584) although there was a trend for

those with some post-secondary education to believe

that it was commonly used in their sport. When these

responses were analysed with respect to injury

duration, 29.1% of the respondents indicated that

it was commonly used in their sport while 32.7%

were not sure of the frequency of its use. Once again,

there was no significant difference (Table V) on

knowledge about boosting and injury duration of the

respondents (Fisher’s Exact (12, N¼ 55), p¼ 0.217),

although there was a trend for those with 16þ yrs

injury duration to believe that it was more commonly

used.

Twenty-nine (28 males and 1 female) of the 99

participants who responded to this question reported

that boosting was most useful (Figure 2, panel A) 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 events

(57.1%), wheelchair basketball (32.1%), Nordic

skiing (21.4%), alpine skiing (10.7%), throwing

events (10.7%) and other events (3.6%). When

queried about the sport in which boosting would be

the least useful (Figure 2, panel B), a majority of the

respondents identified throwing events (55.6%) and

alpine skiing (51.9%). Smaller percentages of the

respondents identified middle distance (3.7%), long

distance (11.1%) and marathon racing (25.9%) as

the events that were least benefited by boosting.

Corresponding values for sprinting events, wheel-

chair basketball and wheelchair rugby were 25.9,

25.9 and 11.1%, respectively.

A majority of the respondents 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 frequencies of the variables that they felt

benefited the most from boosting during competition

are illustrated in Figure 3. The four most frequently

reported benefits of boosting during competition

were increased circulation, less fatigue and increased arm

endurance along with increased aggression and increased

Table IV. Knowledge of boosting in athletes with high level spinal injury: influence of education level and injury duration (responses to

Question 3b, Appendix A).

Variable

Question 3a: Before reading about it on this questionnaire, have you every heard of boosting as a performance

enhancing strategy?

Education level HSG SPS SU UD GD Total Per cent Fisher Exact

Yes 11 6 6 8 11 42 55.3 p¼0.717

No 12 5 4 5 6 32 42.1

Not sure 2 0 0 0 0 2 2.6

Injury duration 1–5 years 6–10 years 11–15 years 16þ years Total Per cent Fisher Exact

Yes 3 10 12 26 51 58.0 p¼0.120

No 7 7 7 13 34 38.6

Not sure 1 1 0 1 3 3.4

SHS, some high school; HSG, high school graduation; SPS, some post-secondary education; SU, some university (no degree); ED,

undergraduate degree; GD, graduate degree.

Table V. Use of boosting in athletes with high level spinal injury: influence of education level and injury duration.

Variable Question 6: To your knowledge, would you boosting is:

Education level HSG SPS SU UD GD Total Per cent Fisher Exact

Commonly used 2 2 3 2 4 13 27.1 p¼0.584

Infrequently used 4 1 0 2 3 10 20.8

Rarely used 4 0 0 0 1 5 10.4

Not used 2 0 0 0 1 3 6.3

Not sure of its use 4 3 1 6 3 17 35.4

Injury duration 1–5 years 6–10 years 11–15 years 16þ years Total Per cent Fisher Exact

Commonly used 0 2 2 12 16 29.1 p¼0.217

Infrequently used 2 3 3 4 11 20.0

Rarely used 1 2 1 4 8 14.5

Not used 0 1 0 1 2 3.6

Not sure of its use 0 2 8 8 18 32.7

SHS, some high school; HSG, high school graduation; SPS, some post-secondary education; SU, some university (no degree); ED,

undergraduate degree; GD, graduate degree.

2178 Y. Bhambhani et al.

alertness. However, some athletes also reported

increased anxiety and greater frustration as possible

effects of boosting during competition. The respon-

dents reported that the main source of knowledge

was their personal experience (62.5%) and reports

from other athletes (46.4%).

Knowledge pertaining to health effects of boosting

(Question 11)

A summary of the respondents’ knowledge pertain-

ing to the dangers of boosting is provided in Table

VI. Forty-nine percent of the male and female

respondents agreed that boosting was somewhat

dangerous to health. However, 21.1 and 24.6% of

the respondents also felt that boosting was dangerous

or very dangerous to health, respectively. Only a

small proportion (5.3%) felt that boosting was not at

all dangerous to health. In general, both males and

females had a similar opinion regarding the dangers

of boosting. Statistically, there were no significant

differences in the frequency of responses regarding

the dangers of boosting by gender when the category

not dangerous at all was compared to any level of

danger, although males were more spread over the

various categories (Fisher’s Exact (3, N¼ 57),

p¼ 0.615). Similarly, there were no significant

differences in the frequency of responses with respect

to dangers of boosting when they were examined by

education level (Fisher’s Exact (12, N¼ 47),

p¼ 0.106) or the injury duration (Fisher’s Exact (9,

N¼ 54), p¼ 0.421) of the respondents.

With respect to the symptoms of boosting, most of

the respondents identified headache (70.9%), ex-

cessive sweating (80.6%) and high blood pressure

(83.3%) as the most frequent ones. Shivering

(36.8%) and blurred vision (26%) were less fre-

quently reported by them. The frequencies of these

symptoms are illustrated in Figure 4. The main

source of knowledge regarding the symptoms of

boosting was their personal experience (61.7%) and

reports from other athletes (50%). The respondents

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%) as possible

outcomes. Only a small proportion (16.1%) identi-

fied seizures as a possible consequence of boosting.

Attitude towards boosting

A majority of the males and females indicated that

using boosting to improve training capacity, max-

imise performance during competition, and because

their competitors were using it was unacceptable.

There was no significant gender difference in the

frequency of the responses to this question (Fisher’s

Figure 2. Events that will most (panel A) and least (Panel B) likely

benefit from boosting in high-level spinal injured athletes (N¼29

responses). MR, marathon racing; LDE, long distance events;

MDE, middle distance events; SPR, sprint races; THR, throwing

events; WCB, wheelchair basketball; WCR, wheelchair rugby; NS,

Nordic skiing; AS, Alpine skiing; OTH, other events. Note: only

one female participant responded to this question. Her response is

illustrated in wheelchair rugby. Many athletes participated in more

than one sport, and therefore, the total of all the frequencies

exceeds 100%.

Figure 3. Variables that would benefit the most from boosting

during competition (N¼50 responses). IAST, increased arm

strength; IAE,¼ increased arm endurance; LAS, less arm stiffness;

LDB, less difficulty breathing; IC, increased circulation; LF, less

fatigue; IAG, increased aggression; IAL, increased alertness; IAN,

increased anxiety; IF, increased frustration.

Boosting in paralympic athletes 2179

Exact (4, N¼ 61), p¼ 0.875) although there was a

trend according to the descriptive statistics for males

to see it as being more acceptable. When these

responses were analyzed with respect to level of

education, there were no significant differences in

the frequency of these responses in either gender

(Fisher’s Exact (16, N¼ 51), p¼ 0.773). Evaluation

of these responses with respect to injury duration

revealed that there was no significant influence in

either gender (Fisher’s Exact (12, N¼ 58),

p¼ 0.793). When queried whether boosting should

not be banned because it can happen unintentionally their

opinion was split. Approximately 25% of the

respondents found this unacceptable while 37% were

in agreement with the statement. Similarly, the

respondents expressed a range of views about the

statement: boosting should not be banned because any

athlete with T6 or higher spinal cord injury can decide to

induce AD. Statements that the majority of the

respondents did not agree with included: (1) only

practices that are not available to all athletes in the

same class should be banned and (2) showcasing the

talents of athletes, and by extension the capabilities

of people with disabilities, is far more important than

whether or not someone is boosting.

Discussion

A total of 99 athletes participated in this study, with

the majority (89%) of them being males. It is not

surprising, therefore, that the males demonstrated

considerable variability with respect to their age, level

of education, employment status and source of

funding compared to the females (Table I). The

male participants also had greater variability with

respect to the level of injury (C5 to T6) and duration

of injury (1–18 yrs) compared to the females (C5 to

T4 and 3–16 yrs, respectively) (Table II). It is

noteworthy that only 25% of the combined sample

was within the 16–27 year age group, while 20% was

above 40 yrs old. Approximately 55% of the overall

sample was within the 28- to 40-yr age range, which

was likely an artifact of many having sustained their

spinal cord injuries later in life and, consequently,

launched their paralympic sport careers later as well.

Also, many of these athletes devoted several yrs to

training post-injury before becoming elite athletes,

which further contributes to the advanced age. The

participants in this study represented three main

summer sports, namely, athletics (track and field),

wheelchair basketball and wheelchair rugby. A

majority of them competed in wheelchair rugby

(54.2%), followed by wheelchair track events (mara-

thon, long distance, middle distance and sprints;

32%), wheelchair basketball (9.4%) and field events

(6.3%).

Table VI. Knowledge of dangers of boosting in athletes with high-level spinal injury: influence of education level and injury duration.

Variable Question 6: To your knowledge, would you boosting is:

Gender Male Female Total Per cent Fisher Exact

Not at all dangerous 3 0 3 5.3 p¼0.615

Somewhat dangerous 24 4 28 49.1

Dangerous 12 0 12 21.1

Very dangerous 13 1 14 24.6

Education level HSG SPS SU** UD GD Total Per cent Fisher Exact

Not at all dangerous 1 0 0 1 0 2 p¼0.106

Somewhat dangerous 5 2 1 8 7 23

Dangerous 2 3 2 0 3 10

Very dangerous 5 0 3 1 3 12

Injury duration 1–5 years 6–10 years 11–15 years 16þ years Total Per cent Fisher Exact

Not at all dangerous 0 1 1 1 3 p¼0.421

Somewhat dangerous 1 5 10 11 27

Dangerous 0 3 2 5 10

Very dangerous 2 2 1 9 14

SHS, some high school; HSG, high school graduation; SPS, some post-secondary education; SU, some university (no degree); ED,

undergraduate degree; GD, graduate degree.

Figure 4. Symptoms of boosting reported by respondents with

high-level spinal injuries (N¼58 responses). HEAD, headache;

SHIV, shivering; SWEAT, excessive sweating; HBP, high blood

pressure; BV, blurred vision.

2180 Y. Bhambhani et al.

The current results indicated that 52 of the 96

participants whose gender was known (54.1%) had

previously heard of boosting to enhance perfor-

mance, while 40.1% of them were unaware of this

practice and the remainder was unsure. Contrary to

our hypothesis, awareness was significantly greater in

males compared to female participants and did not

differ by the age and the injury duration (Table III)

of the participants in either gender. Although male

participants who had university undergraduate or

postgraduate degrees were more aware of this

practice, this finding should be interpreted with

caution due to the relatively small number of

participants. A similar finding was observed with

respect to the duration of injury; i.e. those who had

longer injury histories tended to have greater

awareness of boosting than their counterparts with

less history. For athletes with spinal cord injuries

above T6 in particular, knowledge of boosting was

limited and makes them, along with women athletes

prime audiences to target educational initiatives.

Only 60 of the 99 participants responded to the

question: Have you every intentionally induced AD to

boost your performance in training or competition. The

reason for the low response rate to this question is

not known, but it could be due to their apprehension

for disclosing information that could possibly in-

criminate them in a technique that is deemed illegal

by the IPC (www.paralympic.org). This was despite

the questionnaire being designed to ensure anonym-

ity; the participants were not required to provide

their name or country of origin on the questionnaire.

Furthermore, the participants deposited the com-

pleted questionnaire into a mailbox and not to any of

the investigators involved in the study Consistent

with our hypothesis, 15.5% (9 of 58) indicated that

they had previously used boosting to enhance

performance in training or competition, while the

remaining 84.5% had not used this method. It is

particularly noteworthy that all the respondents who

used this method were males (Note: one respondent

did not identify their gender), with a majority of

them competing in wheelchair rugby (five of nine or

55.5% of the respondents). The other four positive

responses were received from athletes who competed

in long- and middle-distance wheelchair racing

events. Our finding that a majority of the ‘boosters’

were wheelchair rugby players was most likely

because they comprised the largest proportion

(54.2%) of the respondents in this study. With

respect to the frequency of boosting, approximately

two-thirds of the athletes indicated that they had not

used it during training or during national and

international competitions. A small percentage of

the participants (6–14%) reported using this techni-

que to enhance performance during training and

competition, while only one participant indicated

that he used it all the time in national and

international competitions to enhance performance.

The observation that several participants used

boosting during training is of serious concern

because most athletes, particularly those competing

in individual sports, tend to train on their own with

minimal amount of supervision. The possibility of an

adverse event due to an exaggerated blood pressure

response resulting from boosting during training has

important implications for developing educational

programmes pertaining to this practice.

The results of this preliminary investigation

indicated that the incidence of boosting did not

differ by the age of the respondents (Table III).

This is most likely because a spinal cord injury can

occur at any stage in life, and therefore, may not

have any bearing on the athlete’s decision to boost

or not to boost. Theoretically, it is likely that

respondents with the higher lesion levels would

most likely benefit the most from boosting.

However, the current findings revealed that there

was no significant difference in the incidence of

boosting by the level of spinal injury of the

respondents. To further explore this question, the

difference in the incidence of boosting between

respondents who spontaneously experienced AD

(Question 22) and those who decided to boost

themselves to enhance performance during training

and/or competition was examined (Question 3b).

Once again, the results indicated that there was no

significant difference (Fisher Exact (2, N¼ 48),

p¼ 0.312) by these two variables, suggesting that

prior experience of AD did not influence the

respondents’ decision to boost for performance

enhancement. However, contrary to our hypoth-

esis, the incidence of boosting was significantly

associated with the level of education of the

respondents (Table III). Those who had graduate

university degrees (N¼ 4) boosted more frequently

when compared to respondents who had some high

school (N¼ 0) and some post-secondary (N¼ 3)

education. The theoretical reason(s) for these

findings are unclear at present and need to be

further investigated. However, this finding should

be interpreted with caution because of the small

number of subjects that boosted in each of the

educational categories.

Knowledge pertaining to the effects of boosting on

athletic performance was quite varied. Approxi-

mately 40% of the athletes believed that boosting

definitely had a beneficial effect on some sports,

while an equal proportion was unsure of such

benefits. Wheelchair racing events such as the

marathon, long distance and middle distance races

(Figure 3) were identified by the majority of the

respondents as the sports that would most benefit

from boosting. From a physiological standpoint,

Boosting in paralympic athletes 2181

these races are primarily dependent upon aerobic

metabolism and would therefore benefit the most

when the athletes are in a boosted state [10,11].

What is surprising, however, is that 64.3% of the

respondents also indicated that boosting would

benefit wheelchair rugby performance which is a

high intensity, intermittent sport that is not depen-

dent primarily upon aerobic metabolism. It is

possible that factors such as increased aggression

and alertness [12] that were reported by some

athletes (Figure 3), which could be attributed to

the enhanced catecholamine response in the boosted

state during exercise [11,13], could explain this

response. A recent study [14] on professional able-

bodied rugby players suggested that players with high

levels of self-reported aggression were more likely to

use excessive force to injure an opponent and obtain

an advantage during the game. As well, it has been

documented [15] that hormonal changes (testoster-

one and cortisol) during competition in able-bodied

karate athletes could interact with their personality

traits to enhance competitive performance. Research

along these lines should be conducted on athletes

with disabilities to validate these findings.

The current findings support the hypothesis that

athletes of both genders would demonstrate awareness

of the signs and symptoms pertaining to boosting.

Approximately 50% of the respondents felt that

boosting was somewhat dangerous, while 46% of

them reported that it was dangerous or very dangerous

to health. Further analysis revealed that 7 of 9

respondents who had used boosting indicated that it

was somewhat dangerous to health, while one respon-

dent indicated that it was very dangerous and the

remaining one felt that it was not at all dangerous to

health. Excessive sweating, high blood pressure and

headache were identified as the most frequent

symptoms of boosting, while shivering and blurred

vision were reported less frequently. Two of these

symptoms, namely excessive sweating and shivering,

are easily visible and are frequently used to identify

whether spinal cord injured athletes are in the boosted

state during competitions [6]. When queried about the

consequences of boosting, approximately 60% of the

respondents identified stroke/cerebral haemorrhage

and 44% identified death as possible outcomes. The

awareness of the signs/symptoms and consequences of

boosting was not associated with their education level

or injury duration. Respondents indicated that they

gained most of this knowledge through their personal

experiences or from discussions with other athletes.

Only 22.9% of them indicated that they learned about

boosting from reading, while 2.1% leaned about it

from their coaches. These findings are not surprising

because of the following reasons. First, although much

has been written about the clinical effects of AD which

occurs spontaneously [16–18], there is minimal

published scientific information pertaining to its

voluntary induction (i.e. boosting) that is available

to athletes. The available boosting studies have

focused strictly on the physiological responses of

the athletes during exercise [1,11,13]. Second, the

findings of two surveys [10,19] indicated that a

majority of the elite athletes with disabilities do not

have professionally trained coaches, and therefore,

rely on themselves for acquiring relevant informa-

tion. One former paralympic athlete [20] clearly

stated that education should be given to athletes about all

the aspects of boosting. To permit participation of

‘unboosted’ athletes, new standards should be fixed to

ensure rights for those who do not use boosting. These

findings reiterate the need for developing suitable

educational programs not only for the athletes, but

also for the coaches, trainers and rehabilitation

professionals responsible for their overall health and

safety. The male and female respondents in this

study were strongly opposed to the use of boosting to

improve training capacity, enhance performance

during competition and cause their competitors were

using it. This opinion was independent of their

education level, employment status and duration of

injury. Despite their knowledge pertaining to the

dangers and adverse health effects of boosting

(Figure 4), 16.7% of the respondents indicated that

they had used it to enhance performance during

training and/or competition. This finding should be

of concern to the athletes, coaches and trainers and

the governing bodies of the paralympic sport

organisations.

Random monitoring of athletes suspected of

boosting was first implemented at the Sydney

Paralympic Games in 2000. During the 2008 Beijing

Paralympic Games, a total of 20 athletes, 16 wheel-

chair racers and four-hand cyclists were tested for

boosting shortly before competition. This is a

relatively small number compared to the total

number of athletes with high-level spinal cord

injuries that participated in the Games and the

overall number of events in which they competed.

None of these athletes demonstrated a positive

response on the basis of their blood pressure

measurements. However, it is possible that some

athletes could have induced boosting during the

competition and circumvented the initial screening

process. This is difficult to monitor and poses a real

challenge to the procedures for monitoring boosting

in these athletes. The results of this study indicated

that only one participant used boosting all the time

during national and international competitions. It is

recommended that 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.

2182 Y. Bhambhani et al.

Limitations of the study

Because of the relatively small sample size in this

study, the number of responses in the categorical

variables for many of the questions was very low.

Although the Fisher Exact test is specifically de-

signed for small sample sizes (below five per cell), the

current findings were limited by low statistical power

and distortion between categories because of the

small number of respondents in many cells. There-

fore, visual analysis of the descriptive statistics should

be given some weight despite any lack of statistical

significance.

The ratio of male (N¼ 84) to female (N¼ 11)

participants in this study was approximately 8:1. The

gender distribution of the 241 athletes with spinal

injuries above T6 who participated at the Beijing

Paralympic Games is not available, and therefore, it

is not clear whether the present distribution is

representative of their participation in the Games.

It is likely, however, that the males who met the

inclusion criteria outnumbered the females, because

all but one of the participants in wheelchair rugby,

the sport that comprised 96 of the 241 athletes

(40%), were males. Generalising the results of this

study to the female Paralympic population should be

viewed with caution.

The current questionnaire was administered only

in English, and therefore, was completed by indivi-

duals who were familiar with this language. There-

fore, the findings from this study could be

generalized mainly to athletes who could commu-

nicate in English. However, in some instances, non-

English speaking athletes (e.g., Brazil and Italy) were

assisted by their coaches and team managers in

completing the questionnaire during the Games and

are included in the total sample.

In the interest of ensuring anonymity of the

participants, the Health Research Ethics Board at

the University of Alberta stipulated that they not be

required to identify their country of residence on the

questionnaire. Therefore, it was not possible to

conduct an analysis of the results with respect to

the country of origin in this study. It is possible that

regional differences pertaining to boosting may exist,

and further research should be conducted to examine

this question.

The use of a self-report questionnaire to obtain

information on a sensitive issue such as doping runs

the risk of under-reporting by the athletes, and

therefore, could be misleading [21]. As well, the

reproducibility of the responses to these sensitive

issues may be questionable [22]. From a research

perspective, it is crucial that the perspectives of the

athletes’ be accurately documented, so that appro-

priate intervention strategies can be implemented by

the sport governing bodies.

Recommendations

This is the first study that has systematically

examined the incidence, knowledge and attitudes

towards boosting in paralympic athletes with high-

level spinal cord injuries. The lack of previous

research pertaining to this topic makes it difficult to

place the current results in perspective. However,

based on these findings, the following recommenda-

tions are made:

1. Educational materials pertaining to AD are

developed in simple language that can be

understood by individuals with SCI and

rehabilitation professionals responsible for

their regular care.

2. Specific educational materials pertaining to

the effects of boosting during exercise are

developed so that paralympic athletes can

increase their awareness and knowledge

about this method of doping which can be

dangerous to their health.

3. A concerted effort should be made to

increase boosting awareness in females as

they demonstrated considerable lack of

knowledge in this area.

4. Educational materials are developed in an

interactive manner in different languages so

as to enhance knowledge and learning by the

athletes, coaches and trainers internationally.

5. Coaches and trainers should be educated

about this practice and convey this informa-

tion to their athletes so that the overall

incidence of boosting can be reduced.

6. Boosting educational programmes be tar-

geted in geographical regions where the

awareness is most likely to be low.

7. Boosting programmes be initiated at the

junior level so that these individuals are fully

aware of its dangers when they become

competitive athletes.

8. Boosting workshops during the paralympic

games and other sanctioned competitions

should be considered so as to further educate

the athletes, coaches and trainers regarding

this practice.

9. Educational programmes be targeted to

specific sports (e.g. wheelchair rugby, wheel-

chair distance racing) in which the incidence

of boosting is likely to be high.

10. Increase the frequency of boosting tests at

sanctioned competitions so that the trends in

this practice can be systematically evaluated.

11. Further research should be conducted on a

larger sample size of competitive spinal cord

injured athletes of both genders with lesion

levels above T6 so that the findings can be

Boosting in paralympic athletes 2183

generalised to a larger segment of this

population.

Acknowledgements

We thank the following organisations and individuals

for facilitating this research study:

. World Anti-Doping Agency (WADA) for their

financial support.

. International Paralympic Committee (IPC) for

their administrative assistance in implementing

this study through their head office in Bonn

and at the Paralympic Games in Beijing.

. The IPC Sports Science Committee for its

approval of the study to be conducted at the

Beijing 2008 Paralympic Games.

. Dr. Wendy Rodgers, Professor, Faculty of

Physical Education and Recreation, University

of Alberta for reviewing the first draft of the

questionnaire.

. Dr. Kelly MacKay, Associate Dean (Aca-

demic) Faculty of Kinesiology and Recreation

Management, University of Manitoba for

reviewing the second draft of the questionnaire.

. Managers of the National Paralympic Com-

mittees for encouraging their athletes to

participate in this study.

. Team coaches who took the responsibility of

distributing the questionnaires to the athletes

and returning them in a timely fashion.

. Susan Armijo Olivo and Patricia Edney from

the Rehabilitation Research Center, University

of Alberta, for their assistance in conducting

the statistical analyses.

. All the participants who took the time to

complete this questionnaire during the Paral-

ympic Games in Beijing and via the on-line

submission process. Without your cooperation,

this research study would not have been

possible!

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Appendix. Validated boosting questionnaire

What is Boosting?

Some individuals with a high level spinal cord injury (SCI), usually above the T6 level, experience a reflex

condition known as autonomic dyreflexia in their daily lives. Some athletes with spinal cord injury may voluntarily

induce autonomic dysreflexia, which is commonly called boosting, to improve their performance.

The purpose of this questionnaire is to learn more about the perspectives of elite athletes on sport and

performance enhancing practices, particularly boosting, in the Paralympic movement. All the information on the

questionnaire is anonymous and completely confidential, and will not be used to identify you individually or to

compromise your eligibility to compete in IPC sanctioned competitions. Please feel free to skip any questions

you are not comfortable answering and to add any additional comments about the research that you deem

appropriate. If you need more space for your answers, please use the back of the pages or attach additional ones.

Thank you very much for your valued time and contribution! Please return your completed questionnaire to

the person who invited you to participate or directly to the IPC (see address below).

1. Before reading about it on this questionnaire, have you ever heard of boosting as a performance enhancing

strategy? Please check [�] one.

¤ Yes (go to question 2)

¤ No (go to question 16)

¤ Not sure (go to question 16)

2. If you answered yes to the previous question, would you define boosting in any way other than described in

the introduction to this questionnaire? If so, how.

3a. Based on your injury/lesion level is it possible for you to experience autonomic dysreflexia?

¤ Yes

¤ No (go to question 6)

3b. If you answered yes to question 3a, have you ever intentionally induced autonomic dysreflexia to boost

your performance in training or competition?

¤ Yes

¤ No

4. With 1 being never and 5 being all the time, please circle (�) the number that best reflects how often you use

boosting in: If you answered NO to question 3a please circle 6.

5. Who monitors your use of boosting during: Please check [�] all that apply.

Never Sometimes All the time Not applicable

Your regular training program: � � � � � �Your peaking for competition training program: � � � � � �National competitions: � � � � � �International competitions: � � � � � �

You Coach Doctor Other No one Not applicable

Regular training program: ¤ ¤ ¤ ¤ ¤ ¤Peaking for competition training ¤ ¤ ¤ ¤ ¤ ¤National competitions: ¤ ¤ ¤ ¤ ¤ ¤International competitions: ¤ ¤ ¤ ¤ ¤ ¤

Boosting in paralympic athletes 2185

6. To your knowledge, would you say boosting is:

¤ Commonly used in your sport ¤ Not used in your sport

¤ Infrequently used in your sport ¤ I am not sure of its use

¤ Rarely used in your sport

7. When do you think boosting is most useful? Please check [�] all that apply.

¤ In training ¤ During competition

¤ Immediately before competition ¤ Other: please explain

8. Do you think boosting is more useful in some sports than others?

¤ Yes, please answer question 9a and 9b

¤ No, please go to question #10a

¤ Do not know, please go to question #10a

9a. Which sports/events do you think boosting is most useful? Please check [�] all that apply.

¤ Wheelchair Athletics ¤ Wheelchair Basketball

¤ Marathon racing ¤ Quad Rugby

¤ Long distance events ¤ Nordic Skiing

¤ Middle distance events ¤ Alpine Skiing

¤ Sprints ¤ Other, please specify

¤ Throwing events

9b. Which sports/events do you think boosting is least useful? Please check [�] all that apply.

¤ Wheelchair Athletics ¤ Wheelchair Basketball

¤ Marathon racing ¤ Quad Rugby

¤ Long distance events ¤ Nordic Skiing

¤ Middle distance events ¤ Alpine Skiing

¤ Sprints ¤ Other, please specify

¤ Throwing events

10a. Of the listed items, which do you believe boosting affects and at what point in time (e.g., before, during or

after the event). Please check [�] that apply.

In Training

Immediately Before

Competition During Competition After Competition

Yes No Not Sure Yes No Not Sure Yes No Not Sure Yes No Not Sure

Increased arm strength

Increased arm endurance

Less arm stiffness

Less difficulty breathing

Improved circulation

Less fatigue

Increased aggression

Increased alertness

Increased anxiety

Increased frustration

Other (specify)

2186 Y. Bhambhani et al.

10b. In answering the previous question (10a), what are your responses based on? Please check [�] all that

apply.

¤ Personal experience

¤ Reports form other athletes you know personally

¤ Coaches

¤ Reading

¤ Other (Specify):

11. Based on what you know about boosting, would you say it is:

¤ Not at all dangerous

¤ Somewhat dangerous

¤ Dangerous

¤ Very dangerous

12a. Which of the following, if any, do you believe are symptoms of boosting. Please check [�] all that apply.

12b. In answering the previous question (12a), what is your main source of information? Please check [�] all

that apply.

¤ Personal experience

¤ Reports form other athletes you know personally

¤ Coaches

¤ Reading

¤ Other (Specify):

13. Which, if any, of the listed health risks do you think are possible consequences of boosting and how do you

know this? Please check [�] all that apply.

Symptom Yes No Not Sure

Headache

Shivering

Excessive Sweating

High blood pressure

Blurred vision

Other (specify)

Information Sources

Possible consequence Yes No Not Sure Personal Experience Other Athletes Coaches Reading Other (specify)

High blood pressure

Seizures

Stroke/cerebral haemorrhage

Death

Other (specify)

Boosting in paralympic athletes 2187

14. With 1 being totally not acceptable and 5 being totally acceptable, please circle (�) the number that best

reflects your opinion about boosting.

15. Please circle (�) the number that best reflects the extent to which you agree (1¼ strongly disagree and

5¼ strongly agree) with the following statements.

16. In the column provided please list any other methods you currently use for improving performance (e.g.,

nutritional supplements, carbohydrate replacement) in training/competition that have not been addressed

in this questionnaire and indicate (�) whether you believe the method/practice to be effective, legal, and

whether it has associated health risks.

17. Recent sport news includes numerous examples of ‘‘doping’’ scandals in sport generally. From your

perspective, which of the following statements best captures your opinion about this issue? With 1 being

totally not acceptable and 5 being totally acceptable, please circle (�) the number that best reflects your

view about each statement.

TotallyNot Acceptable

SometimesAcceptable

TotallyAcceptable

Boosting to improve training capacity is: � � � � �Boosting to maximize performance in competition is: � � � � �Boosting because you know your competitors are is: � � � � �Boostino is: � � � � �

StronglyDisagree

SomewhatAgree

TotallyAgree

Boosting should not be banned becauseit can happen unintentionally.

� � � � �Boosting should not be banned because any athlete with T6

or higher spinal cord injury can decide to induceautonomic dysreflexia.

� � � � �Only practices that are not available to all athletes in

the same class should be banned.� � � � �

The message—show casing the talents of athletes and by extensionthe capabilities of people with disabilities—is far more importantthan whether or not someone is boosting.

� � � � �

Effective Legal Health Risks

Method/Practice Yes No Not Sure Yes No Not Sure Yes No Not Sure

TotallyNot Acceptable

SometimesAcceptable

TotallyAcceptable

Using banned drugs to improve training capacity is: � � � � �Using banned drugs to maximize

performance in competition is:� � � � �

Using banned drugs because youknow your competitors are is:

� � � � �Using banned drugs is: � � � � �

2188 Y. Bhambhani et al.

18. To what extent, if any, do you think doping is a concern in Paralympic Sports? Please check [�] one.

¤ Not a concern at all

¤ Sometimes a concern

¤ A major concern

Please add additional comments to explain your answer to question 18.

Background Information

Questions in this section of the questionnaire are designed to provide background information. Once again, this

information will not be used to identify you but to provide information about the sample group involved in the

research. Please feel free to skip any questions you are not comfortable answering.

19. What is the highest level of education you have completed? Please check [�] one.

¤ Some high school ¤ Undergraduate university degree(s)

¤ High school graduation Specify area:

¤ Some post-secondary (not university) ¤ Graduate university degree Specify area:

¤ Some university (no degree)

20. Which of the following best describes your status? Please check [�] all that apply.

¤ Paid employee � ¤ part-time ¤ full-time

¤ Self employed � ¤ part-time ¤ full-time

Please describe the kind of work you do:

¤ Unemployed � ¤ looking for work ¤ not looking for work

¤ Student � ¤ part-time ¤ full-time

¤ Athlete � ¤ part-time ¤ full-time

As an athlete are you: ¤ self-funded

¤ state/government funded

¤ funded by other source: please specify:

21. Please check [�] the appropriate box for each of the following items

Sex: ¤ Female ¤ Male

Age: ¤ 16 to 21 ¤ 34 to 39

¤ 22 to 27 ¤ 40 to 45

¤ 28 to 33 ¤ 46 and over

22. Have you ever spontaneously (not intentionally induced) experienced autonomic dysreflexia?

¤ Yes (go to question 23)

¤ No (go to question 24)

¤ I don’t know (go to question 24)

23. If you answered yes to question 22, how often does this happen? Please specify:

24. Which sport(s) do you participate in? Please check [�] all that apply.

¤ Wheelchair Athletics ¤ Wheelchair Basketball

¤ Marathon racing ¤ Quad Rugby

¤ Long distance events ¤ Nordic Skiing

¤ Middle distance events ¤ Alpine Skiing

¤ Sprints ¤ Other, please specify

¤ Throwing events

Boosting in paralympic athletes 2189

25a. Please specify the date of your initial spinal cord injury: ______/______/______

Day Month Year

25b. Please specify the lesion level of your injury:

Level of Lesion:

¤ I do not know the lesion level of my injury

25c. Please indicate whether your spinal cord injury: Please check [�] one box only

¤ Complete

¤ Incomplete

¤ I do not know the answers to this question

26. Is there anything else you would like to convey to the IPC about doping, boosting, or any other legal or

banned performance enhancing strategy? If yes, please explain.

2190 Y. Bhambhani et al.

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