Performance Enhancement in Paralympic Athletes: Blood Doping, Boosting, and Beyond.

Blood doping is a well-documented method of performance enhancement that increases red blood cell mass to improve oxygen transport and endurance. While its use in able-bodied athletes has been widely studied, its implications for Paralympic athletes remain understudied despite increasing participation and competitiveness in adapted sports. This review explores the physiological mechanisms of oxygen transport and utilization during exercise, emphasizing how these are affected by various impairments common in Paralympic athletes. It highlights how cardiovascular, respiratory, and muscular limitations in this population may alter both the effectiveness and risks of blood doping. Furthermore, the manuscript discusses the historical context and methods of blood doping, including the unique practice of "boosting" through autonomic dysreflexia. Key challenges in detection are addressed, particularly the variability of hematological markers that complicate standard anti-doping approaches. Health risks such as thrombosis, autonomic instability, and long-term cardiovascular complications are also reviewed. The paper concludes by identifying critical research gaps and advocating for individualized detection methods, longitudinal studies, and tailored education strategies. Given the complex physiology and ethical considerations in this population, a nuanced understanding of blood doping in Paralympic sport is essential for developing effective anti-doping policies and promoting athlete safety and fairness.