Electroceuticals for Paralympic Athletes: A Fair Play and Classification Concern?

Parasport is founded on a simple but powerful principle: that success should be determined by talent, training, and determination, not by who has access to the most advanced technology to support performance. Classification systems and anti-doping policies exist to protect this idea of fair competition. However, a new challenge is emerging.

Electroceuticals are a form of neurotechnology designed to improve or restore neurological functions after injury or disease. Such devices are increasingly showing potential to enhance athletic performance in people with neurological disorders (e.g., spinal cord injury). Whilst this technology can offer profound health benefits, its use in training or competition raises difficult ethical and regulatory questions. Could electroceuticals provide an unfair advantage, pressure athletes into adopting medical devices simply to remain competitive, or undermine the very classification systems designed to level the playing field?

As access to electroceuticals grows, parasport urgently needs a conversation about how innovation and fairness can (and should) coexist.

What are electroceuticals?

Electroceuticals are medical devices that use electrical stimulation to alter the nervous system. In people with neurological disorders, they are designed to restore or improve lost functions.

While the term electroceuticals includes a range of neuromodulation technologies, the most relevant example for parasport is spinal cord stimulation (SCS), which has two main forms. Epidural stimulation involves surgically implanting electrodes over the spinal cord, connected to a small pulse generator. Transcutaneous stimulation is non-invasive, using electrodes placed on the skin to deliver electrical currents to the spinal cord.

Research over the past decade has shown that SCS can restore walking after paralysis, improve core trunk stability, blood pressure regulation, and reduce spasticity after spinal cord injury. These improvements are life-changing and have also been exhibited in other neurological conditions: multiple sclerosis, Parkinson’s, cerebral palsy. Crucially, these effects can also translate into enhanced exercise performance and it is this overlap that presents a central challenge.

How performance enhancement is judged in sport

To decide whether a substance or method should be regulated, the World Anti-Doping Agency (WADA) uses three criteria. A method may be prohibited if it meets at least two of the following:

• It enhances (or has the potential to enhance) sporting performance
• It poses an actual or potential health risk to the athlete
• It violates the spirit of sport

In our recent paper in Sports Medicine, we provide compelling reasons for governing bodies – such as WADA and the International Paralympic Committee (IPC) – to consider regulating electroceutical use in parasport. Below are our four reasons why.

Reason 1: It can enhance performance

For many para-athletes with high-level spinal cord injury, performance is limited not only by muscle function but also by impaired cardiovascular control. Low resting blood pressure and reduced heart rate during exercise can severely limit endurance and power output. However, SCS offers a possible solution.

In one of our studies, participants were able to exercise for up to 19 minutes longer when exercising to exhaustion with epidural and transcutaneous SCS relative to a placebo at the same fixed workload, while also finding it easier.

In another study, epidural SCS improved peak oxygen uptake (i.e., VO_2max) by 26% in a person with tetraplegia – such immediate gains are phenomenal relative to the small margins that often separate podium positions in para-athlete competition.

New unpublished evidence from our ongoing STIMEX-SCI trial at the University of Birmingham also shows that transcutaneous SCS can enhance performance in a single session, whilst also improving fitness with long-term use.

These findings could mean racing faster or sustaining higher workloads more effectively than competitors with similar impairments who do not use the technology. Even if performance enhancement is not the primary reason an athlete uses SCS, the competitive advantage that it brings cannot be ignored.

Reason 2: It could pose health risks if misused

When used appropriately in clinical trials, SCS is generally considered safe. However, sport introduces very different incentives and behaviours.

Without clear guidance, athletes may be tempted to use stimulation at higher intensities, more frequently, or in ways not intended by researchers – particularly in high-stakes competition. There are also unresolved questions around long-term use, device malfunction, durability during collisions in contact sports such as wheelchair rugby, and the vulnerability of implantable devices to cyber interference.

Sport already sees the consequences of athletes feeling pressured to manipulate their physiology to remain competitive, particularly this year with the impending Enhanced Games.

Reason 3: It challenges the spirit of fair competition

A central concern is fairness. Accessibility to electroceuticals will differ based on where an athlete lives and their financial background. Implantable systems such as epidural SCS can cost upwards of $100,000 and are often only available through clinical trials or private healthcare, while even non-invasive devices remain expensive ($15,000 - $40,000) and largely limited to research-use. Although, devices are now receiving FDA approval for people to purchase for their own use.

If access to performance-enhancing technology is determined by geography or financial means, competition risks violating the spirit of sport. There is also the danger that athletes who do not want to use such devices may feel compelled to do so simply to keep up.

Reason 4: It could undermine classification

Classification is the system governed by the IPC that groups para-athletes with similar levels of impairment so that competition outcomes are determined by skill rather than disability. It is fundamental to fairness in parasport.

Because classification relies heavily on functional observation, technologies that acutely alter performance present a particular challenge. By improving strength, stability, endurance or hand/grip function, SCS may alter how an athlete presents during classification assessments. There is also the risk – intentional or otherwise – that an athlete could be classified without using their device, then activate it during competition. When done on purpose, this behaviour is known as intentional representation or ‘classification cheating’ and represents a major threat to the integrity of parasport.

As neurotechnology becomes more widespread, classification systems that do not account for its use may become increasingly vulnerable.

A call to action for governing bodies

To be clear, this is not an argument against innovative technology or against athletes using therapies that improve everyday health and quality of life. Rather, it is a call for proactive oversight where use of such technologies during sport could compromise fairness.

WADA and the IPC have an opportunity to act early. Practical steps could include:

• requiring athletes to declare electroceutical use
• developing guidance on use in competition
• monitoring long-term effects on performance and classification
• educating athletes and support staff about ethical and health implications of electroceuticals

Parasport should not wait for controversies to arise. Proactive, collaborative action is needed now to get ahead of the emerging use of electroceuticals and to protect the principles of fair competition, integrity, and athlete welfare.

If you are an individual with spinal cord injury interested in participating in the STIMEX-SCI trial at the University of Birmingham, we encourage you to email our trial team.