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Autonomic dysreflexia in wheelchair tennis athletes
Wheelchair athletes have a variety of medical conditions. One particular condition, called a spinal cord injury, can pose its own unique challenges. With a spinal cord injury, the brain cannot communicate well with the rest of the body. Some individuals may have weakness in the legs, inability to feel pain, or trouble managing bowel movements or urinating. Additionally, the body does not respond to pain as it normally would and one can be prone to episodes of autonomic dysreflexia.
For this newsletter topic, we will help define autonomic dysreflexia, discuss signs and symptoms, management and also describe boosting.
When a healthy individual has pain, the body reacts by increasing blood pressure. If the pain is very bad, some people may even sweat and their heart rate could increase. Ultimately, the pain subsides and these symptoms resolve. For someone who has had a spinal cord injury at or above the sixth thoracic vertebrae level, the body is not able to turn down this response very well.
Some of the common signs and symptoms during an episode of autonomic dysreflexia include headache, sweating, flushing, hypertension, slow or fast heart rate, goosebumps and pupillary constriction. The condition can be life-threatening because dangerous high blood pressure could lead to possible brain bleed, seizure, heart attack or even death. 
For most individuals, it is rare that the symptoms escalate to requiring the need to go to the hospital. It is important to at least know the basics of how to manage this condition, though.
The initial management involves sitting the athlete upright and loosening tight clothing, identifying and removing the painful stimulus, and monitoring and controlling blood pressure. Common causes of pain include a kinked foley catheter, tight clothing, an ingrown toenail or damaged skin. Of note, an individual with a spinal cord injury may have a baseline resting blood pressure in the 90-100 mmHg systolic range. For this reason, elevations of blood pressure 20-40 mm Hg above baseline are characteristic of an episode of AD. Medication management is typically initiated for a blood pressure of >150 mmHg systolic. 
One should seek medical care if there are concerns of an episode of autonomic dysreflexia.
Interestingly, some athletes may try to take advantage of this response by boosting. Boosting is when an athlete intentionally tries to cause him or herself to have an episode of autonomic dysreflexia. The reason to do this, theoretically, is to increase blood flow to muscles to try to help them work better. Unfortunately, as mentioned above, episodes of autonomic dysreflexia can be life-threatening and, potentially, a medical emergency.
It is not recommended to try boosting as a way to enhance one’s performance. In fact, according to the International Paralympic Committee rules, one could be disqualified from an event if found to be boosting. 
Autonomic dysreflexia is not a commonly encountered condition. It can be life threatening, though, so having a basic awareness of what to look for and how to manage this condition can help improve the health and safety of wheelchair athletes.
Erin Andrade, M.D. is a Physical Medicine & Rehabilitation Specialist at Confluence Health in Wenatchee, Wash. and a member of the USTA National Sports Science Committee.
1. Braddom, R.L., Physical Medicine and Rehabilitation. 2010: Elsevier Health Sciences.
2. Klenck, C. and K. Gebke, Practical management: common medical problems in disabled athletes. Clin J Sport Med, 2007. 17(1): p. 55-60.
3. "Autonomic Dysreflexia and Boosting: Lessons from an athlete survey" (PDF). International Paralympic Committee. Retrieved 7 July 2018. https://www.paralympic.org/sites/default/files/document/120131183408508_Thompson_Autonomic_Dysreflexia_and_Boosting.pdf
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