Uncovering the Spectrum of Orthostatic Hypotension in Athletes with Spinal Cord Injury: Implications for Diagnosis, Classification, and Performance

MOHAMED GOMAA SOBEEH; RAZA N. MALIK; THOMAS THORDARSON; KATHARINE D. CURRIE; MICHÈLE HUBLI; CHRISTOPHER R. WEST; RAHUL SACHDEVA; ANDREI KRASSIOUKOV

doi:10.1249/MSS.0000000000003859

Uncovering the Spectrum of Orthostatic Hypotension in Athletes with Spinal Cord Injury: Implications for Diagnosis, Classification, and Performance

MOHAMED GOMAA SOBEEH
, RAZA N. MALIK
, THOMAS THORDARSON
, KATHARINE D. CURRIE
, MICHÈLE HUBLI
, CHRISTOPHER R. WEST
, RAHUL SACHDEVA
, ANDREI KRASSIOUKOV

Research output: Contribution to journal › Article › peer-review

2 Scopus citations

Abstract

Background: – Orthostatic hypotension (OH) is classified into three subtypes based on when blood pressure drops during an orthostatic challenge: initial (IOH; within <15 s), classic (COH; within 3 min), and delayed (DOH; after 3 min). These subtypes have varying degrees of sympathetic dysfunction. OH subtypes have not been characterized after spinal cord injury (SCI), potentially leaving many undiagnosed. This study determined the prevalence and severity of autonomic impairment across OH subtypes in SCI athletes. Method: – Ninety-nine Paralympic athletes with chronic SCI underwent blood pressure and heart rate assessments while supine and during a sit-up test to classify OH subtypes. Autonomic functions were assessed using the Valsalva maneuver (VM) and by calculating Valsalva ratio, total recovery, pressure recovery time, and overshoot. Finally, we examined the distribution of OH across the International Wheelchair Rugby Federation (IWRF) Classification in SCI-rugby athletes. Results: – Notably, 33.3% of the athletes experienced OH, which included 10.1% with IOH, 9.1% with COH, and 14.1% with DOH. Compared with athletes without OH, those with OH exhibited prolonged pressure recovery time (P = 0.02) and blunted overshoot (P = 0.006) during VM. The altered VM metrics were associated with hemodynamic changes during the sit-up test. OH presence was distributed throughout all IWRF classifications. Conclusions: – SCI athletes can experience different subtypes of OH that might interfere with sports performance and cognition. Recognizing athletes with DOH is important since this group may be missed if their orthostatic challenge test is terminated early. Evaluation of VM outcomes could supplement an orthostatic challenge to provide valuable insight into autonomic dysfunctions after SCI. Future research is required to check how the presence of OH throughout IWRF classifications can affect performance.

Original language	English
Pages (from-to)	287-296
Number of pages	10
Journal	Medicine and Science in Sports and Exercise
Volume	58
Issue number	2
DOIs	https://doi.org/10.1249/MSS.0000000000003859
State	Published - Feb 2026

Bibliographical note

Publisher Copyright:
Copyright © 2025 by the American College of Sports Medicine

Funding

The authors thank Cheryl Niamath for her valuable assistance with the figure design. A. K. holds the Patrik Reid Endowed Chair in Rehabilitation Medicine, University of British Columbia. M. G. S. is supported by funds from the Rick Hansen Foundation; R. N. M. is supported by the Paralyzed Veterans of America, Rick Hansen Foundation, Michael Smith Health Research BC, The Canadian Training Platform for Trials Leveraging Existing Networks (CAN-TAP-TALENT), and the CANadian Consortium of Clinical Trial TRAINing platform (CANTRAIN). R. S. is supported by the WFLSCRF and the US Department of Defense. The remaining authors have no conflicts of interest. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. The results of the present study do not constitute endorsement by the American College of Sports Medicine. This work was supported by funding to the laboratory of A. V. K. from the Canadian Foundation for Innovation, BC Knowledge Translation Foundation, the Canadian Institute for Health Research, and the Craig H. Neilsen Foundation.

Funders
Rick Hansen Foundation
Michael Smith Foundation for Health Research
US Department of Defense
BC Knowledge Translation Foundation
Craig H. Neilsen Foundation
Canada Foundation for Innovation
WFLSCRF
Paralyzed Veterans of America
Canadian Institutes of Health Research

Keywords

AUTONOMIC DYSFUNCTION
INTERNATIONAL WHEELCHAIR RUGBY FEDERATION
ORTHOSTATIC HYPOTENSION
SPINAL CORD INJURY
SUBTYPES

ASJC Scopus subject areas

Physical Therapy, Sports Therapy and Rehabilitation
Orthopedics and Sports Medicine

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10.1249/MSS.0000000000003859

Cite this

SOBEEH, MOHAMED. GOMAA., MALIK, RAZA. N., THORDARSON, THOMAS., CURRIE, KATHARINE. D., HUBLI, MICHÈLE., WEST, CHRISTOPHER. R., SACHDEVA, RAHUL., & KRASSIOUKOV, ANDREI. (2026). Uncovering the Spectrum of Orthostatic Hypotension in Athletes with Spinal Cord Injury: Implications for Diagnosis, Classification, and Performance. Medicine and Science in Sports and Exercise, 58(2), 287-296. https://doi.org/10.1249/MSS.0000000000003859

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title = "Uncovering the Spectrum of Orthostatic Hypotension in Athletes with Spinal Cord Injury: Implications for Diagnosis, Classification, and Performance",

abstract = "Background: – Orthostatic hypotension (OH) is classified into three subtypes based on when blood pressure drops during an orthostatic challenge: initial (IOH; within <15 s), classic (COH; within 3 min), and delayed (DOH; after 3 min). These subtypes have varying degrees of sympathetic dysfunction. OH subtypes have not been characterized after spinal cord injury (SCI), potentially leaving many undiagnosed. This study determined the prevalence and severity of autonomic impairment across OH subtypes in SCI athletes. Method: – Ninety-nine Paralympic athletes with chronic SCI underwent blood pressure and heart rate assessments while supine and during a sit-up test to classify OH subtypes. Autonomic functions were assessed using the Valsalva maneuver (VM) and by calculating Valsalva ratio, total recovery, pressure recovery time, and overshoot. Finally, we examined the distribution of OH across the International Wheelchair Rugby Federation (IWRF) Classification in SCI-rugby athletes. Results: – Notably, 33.3\% of the athletes experienced OH, which included 10.1\% with IOH, 9.1\% with COH, and 14.1\% with DOH. Compared with athletes without OH, those with OH exhibited prolonged pressure recovery time (P = 0.02) and blunted overshoot (P = 0.006) during VM. The altered VM metrics were associated with hemodynamic changes during the sit-up test. OH presence was distributed throughout all IWRF classifications. Conclusions: – SCI athletes can experience different subtypes of OH that might interfere with sports performance and cognition. Recognizing athletes with DOH is important since this group may be missed if their orthostatic challenge test is terminated early. Evaluation of VM outcomes could supplement an orthostatic challenge to provide valuable insight into autonomic dysfunctions after SCI. Future research is required to check how the presence of OH throughout IWRF classifications can affect performance.",

keywords = "AUTONOMIC DYSFUNCTION, INTERNATIONAL WHEELCHAIR RUGBY FEDERATION, ORTHOSTATIC HYPOTENSION, SPINAL CORD INJURY, SUBTYPES",

author = "SOBEEH, \{MOHAMED GOMAA\} and MALIK, \{RAZA N.\} and THOMAS THORDARSON and CURRIE, \{KATHARINE D.\} and MICH{\`E}LE HUBLI and WEST, \{CHRISTOPHER R.\} and RAHUL SACHDEVA and ANDREI KRASSIOUKOV",

note = "Publisher Copyright: Copyright {\textcopyright} 2025 by the American College of Sports Medicine",

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doi = "10.1249/MSS.0000000000003859",

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SOBEEH, MOHAMEDGOMAA, MALIK, RAZAN, THORDARSON, THOMAS, CURRIE, KATHARINED, HUBLI, MICHÈLE, WEST, CHRISTOPHERR, SACHDEVA, RAHUL & KRASSIOUKOV, ANDREI 2026, 'Uncovering the Spectrum of Orthostatic Hypotension in Athletes with Spinal Cord Injury: Implications for Diagnosis, Classification, and Performance', Medicine and Science in Sports and Exercise, vol. 58, no. 2, pp. 287-296. https://doi.org/10.1249/MSS.0000000000003859

TY - JOUR

T1 - Uncovering the Spectrum of Orthostatic Hypotension in Athletes with Spinal Cord Injury

T2 - Implications for Diagnosis, Classification, and Performance

AU - SOBEEH, MOHAMED GOMAA

AU - MALIK, RAZA N.

AU - THORDARSON, THOMAS

AU - CURRIE, KATHARINE D.

AU - HUBLI, MICHÈLE

AU - WEST, CHRISTOPHER R.

AU - SACHDEVA, RAHUL

AU - KRASSIOUKOV, ANDREI

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N2 - Background: – Orthostatic hypotension (OH) is classified into three subtypes based on when blood pressure drops during an orthostatic challenge: initial (IOH; within <15 s), classic (COH; within 3 min), and delayed (DOH; after 3 min). These subtypes have varying degrees of sympathetic dysfunction. OH subtypes have not been characterized after spinal cord injury (SCI), potentially leaving many undiagnosed. This study determined the prevalence and severity of autonomic impairment across OH subtypes in SCI athletes. Method: – Ninety-nine Paralympic athletes with chronic SCI underwent blood pressure and heart rate assessments while supine and during a sit-up test to classify OH subtypes. Autonomic functions were assessed using the Valsalva maneuver (VM) and by calculating Valsalva ratio, total recovery, pressure recovery time, and overshoot. Finally, we examined the distribution of OH across the International Wheelchair Rugby Federation (IWRF) Classification in SCI-rugby athletes. Results: – Notably, 33.3% of the athletes experienced OH, which included 10.1% with IOH, 9.1% with COH, and 14.1% with DOH. Compared with athletes without OH, those with OH exhibited prolonged pressure recovery time (P = 0.02) and blunted overshoot (P = 0.006) during VM. The altered VM metrics were associated with hemodynamic changes during the sit-up test. OH presence was distributed throughout all IWRF classifications. Conclusions: – SCI athletes can experience different subtypes of OH that might interfere with sports performance and cognition. Recognizing athletes with DOH is important since this group may be missed if their orthostatic challenge test is terminated early. Evaluation of VM outcomes could supplement an orthostatic challenge to provide valuable insight into autonomic dysfunctions after SCI. Future research is required to check how the presence of OH throughout IWRF classifications can affect performance.

AB - Background: – Orthostatic hypotension (OH) is classified into three subtypes based on when blood pressure drops during an orthostatic challenge: initial (IOH; within <15 s), classic (COH; within 3 min), and delayed (DOH; after 3 min). These subtypes have varying degrees of sympathetic dysfunction. OH subtypes have not been characterized after spinal cord injury (SCI), potentially leaving many undiagnosed. This study determined the prevalence and severity of autonomic impairment across OH subtypes in SCI athletes. Method: – Ninety-nine Paralympic athletes with chronic SCI underwent blood pressure and heart rate assessments while supine and during a sit-up test to classify OH subtypes. Autonomic functions were assessed using the Valsalva maneuver (VM) and by calculating Valsalva ratio, total recovery, pressure recovery time, and overshoot. Finally, we examined the distribution of OH across the International Wheelchair Rugby Federation (IWRF) Classification in SCI-rugby athletes. Results: – Notably, 33.3% of the athletes experienced OH, which included 10.1% with IOH, 9.1% with COH, and 14.1% with DOH. Compared with athletes without OH, those with OH exhibited prolonged pressure recovery time (P = 0.02) and blunted overshoot (P = 0.006) during VM. The altered VM metrics were associated with hemodynamic changes during the sit-up test. OH presence was distributed throughout all IWRF classifications. Conclusions: – SCI athletes can experience different subtypes of OH that might interfere with sports performance and cognition. Recognizing athletes with DOH is important since this group may be missed if their orthostatic challenge test is terminated early. Evaluation of VM outcomes could supplement an orthostatic challenge to provide valuable insight into autonomic dysfunctions after SCI. Future research is required to check how the presence of OH throughout IWRF classifications can affect performance.

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KW - ORTHOSTATIC HYPOTENSION

KW - SPINAL CORD INJURY

KW - SUBTYPES

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Uncovering the Spectrum of Orthostatic Hypotension in Athletes with Spinal Cord Injury: Implications for Diagnosis, Classification, and Performance

Abstract

Bibliographical note

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Keywords

ASJC Scopus subject areas

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