Table I.

Contributions retrieved from the PubMed database (from 1994 onwards) using the key serach terms autonomic dysreflexia, boosting, sport performance.

Authors	Contribution	Results/Conclusions
Harris, 1994	Review/Editorial	It is recommended that all tetraplegic sports people, instructors, trainers and organizers and also the authorities be made fully aware of the technique known as “boosting to produce autonomic dysreflexia”. Investigations and discussions are considered to be necessary and decisions should be taken in order to control the procedure; indeed it would be best if appropriate actions were taken to forbid self-induced autonomic dysreflexia in tetraplegic sports people.
Bhambhani, 2002	Review	Athletes with spinal cord injury have an impaired thermoregulatory capacity and may be more susceptible to thermal stress when compared with able-bodied athletes. Therefore, they should take precautions to minimize the effects of dehydration, heat exhaustion and heat stroke during distance racing events. Wheelchair athletes with quadriplegia who voluntarily induce AD, commonly known as boosting, may enhance distance racing performance by increasing their aerobic power. However, this practice is banned by the IPC not because of its performance enhancing capabilities, but because it could be dangerous to the athletes’ health.
Bhambhani et al., 2010	Study by self-report questionnaire on 99 participants in the Paralympic games	“Of 99 participants, 54.5% had previously heard of AD while 39.4% were unaware; 16.7%, all males, had used AD to enhance performance. Participants reported 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 not influenced by age, injury level or injury duration. Findings indicate the need for educational programs aimed at enhancing the AD knowledge of rehabilitation professionals, coaches and trainers working with SCI individuals.”
Mills and Krassioukov, 2011	Systematic review	“Boosting has been shown to improve sporting performance but can also cause serious complications due to extreme rises in BP. Therefore, boosting has been banned by the IPC. Despite this ban some elite high-level SCI athletes continue to boost. The IPC recognizes that the current classification systems are not the gold standard and further work is needed to create a more evidence-based classification. Further research is needed to determine if the inclusion of ANS parameters contributes to strengthen classifications systems in Paralympic sports. This includes the development of a simple, valid and reliable bedside assessment of autonomic function that can be used to reliably compare athletes with or without ANS dysfunction, thereby enabling further research into the isolated effect of ANS dysfunction on sporting performance.”
Krassioukov, 2012	Systematic review	“Autonomic dysreflexia occurs in up to 90% of individuals with a cervical or high-thoracic SCI and requires prompt intervention. It also is known that, during athletic activities, self-induced AD is used by some individuals to improve their performance, a technique known as “boosting.” For health safety reasons, boosting is officially banned by the IPC. Devastating paralysis, a variety of autonomic dysfunctions, and abnormal cardiovascular control after SCI present significant challenges in terms of individuals remaining active in competitive sports. Medical practitioners who are involved in the care of wheelchair athletes should be aware of the unique cardiovascular dysfunction that results from SCI and may occur at any time, even with seemingly innocuous triggers. Prompt recognition and appropriate management of these conditions, including episodes of AD, could be life saving.”
Blauwet et al., 2013	Study testing the presence of AD in Paralympic athletes prior to competition	“Testing was performed at three major international Paralympic events. […] A total of 78 tests for the presence of AD were performed during the three games combined. No athlete tested positive. […] No athletes were withdrawn from competition due to the presence of AD. […] Knowledge gained during these early testing experiences will be used to guide ongoing refinement of the testing protocol and the development of further educational initiatives.”
Krassioukov and West, 2014	Review/Expert Opinion	“Athletes with SCI have been documented to self-induce autonomic dysreflexia before competition with a view of increasing BP and improving their performance, a technique known as “boosting”. For health safety reasons, boosting is officially banned by the IPC.”

Abbreviations: AD=autonomic dysreflexia; ANS=autonomic nervous system; SCI=spinal cord injury; IPC=International Paralympic Committee; BP=blood pressure