BRINGING SCIENCE TO TREATMENT

Transplant Athletes: using sport to regain health

Organ transplantation provides individuals with a second chance at life. Sports offer physical and mental health benefits for these individuals. However, transplant athletes have unique biopsychosocial challenges when returning to physical activity. Carl Bescoby explores these challenges and discusses how sport could be a useful psychosocial tool to manage an illness, transition to normal life, and increase socialization.

Introduction

Organ transplantation is a medical treatment for end-stage organ failure or chronic illness. Each year, globally, around 135,000 transplants are carried out(1). The increasing frequency of transplant procedures and advancements in medical care have led to a growing number of transplant recipients who must engage in ongoing self-management practices to prolong their health and wellbeing(2). Self-management practices for transplant recipients include daily activities to improve physical and mental functioning. Embedded within self-management practices is a growing emphasis on sport and physical activity to maintain health post-transplant. Given this emphasis, an increasing number of transplant recipients are returning to sport and competing in events such as the World Transplant Games and national-level equivalents, including the British Transplant Games in the United Kingdom(2). However, there are few return to sport (RTS) guidelines for transplant recipients. Therefore, clinicians working with this population may benefit from increased awareness and understanding of these individuals’ biopsychosocial challenges.

Transplant athlete challenges

While it is crucial to understand and promote the health-enhancing benefits of sport, it is also essential to consider alternative ways in which RTS might have value, particularly those central in the context of recipients’ post-transplant lives. Therefore, it is integral to understand the newly transplanted self and how individuals negotiate their physical challenges and manage their new limitations. Furthermore, it is vital to know how fluctuating health impacts individuals’ mental health and wellbeing.

  1. Understanding the newly transplanted individual

When individuals receive an organ transplant, they must come to terms with the transplant, newfound physical capabilities, and limitations. Individuals must rely on immunosuppressive drugs to protect the newly transplanted organ, which requires lifelong management and constant adjustment(3). Immunosuppressive drugs can have severe side effects which may impact health and act as a barrier for RTS. Along with managing these side effects, individuals are at risk of multiple morbidities such as heart disease, diabetes, weight gain, or abdominal discomfort. As a result, they may require another transplant in the future(4,5). The failure of transplanted organs may lead to reduced organ function or a total decline in health, leading to the eventual reduction and or discontinuation of sport.

Despite having to negotiate medication, side effects, and multiple morbidities, transplant recipients can RTS post-transplant, albeit cautiously(6,7). The potential for injury is similar for transplant recipients as the general population. However, transplant recipients face unique challenges, including fractures, hypotension, and risks associated with medications such as myopathies. Furthermore, transplant recipients are encouraged to avoid contact sports or activities that may cause trauma, such as heavy contact sports, including rugby, martial arts, and boxing.

  1. The mental strain of negotiating fluctuating health

Beyond the medical and physical challenges associated with living with a transplant, individuals are at greater risk of experiencing mental ill-health(8,9). Receiving a transplant is considered a treatment, not a cure, and as such, individuals must manage ongoing physical, emotional, and social challenges. Embedded within these health concerns are the shifting identities and social roles that flow from being chronically ill to becoming healthy. Therefore, individuals must manage their changing capabilities from a physical and psychosocial perspective. Often this can cause a significant amount of stress as they find it difficult to position themselves as either healthy or ill but instead are somewhere between the two (see figure 1).

Figure 1: The transplant athlete

Post-transplant, individuals may be anxious that their health could decline at any stage despite physical health improvements and growing capabilities. This is an important consideration when individuals contemplate their athletic status as they move away from their previous illness identity(10). Further, the mental strain associated with constantly negotiating their health status and sporting identity is novel to this sporting population. Therefore, it is crucial for clinicians working with transplant athletes to understand the psychosocial mechanisms of negotiating fluctuating health. In addition, increasing awareness of these fluctuations may help clinicians modify physical programs and sports participation during episodic illnesses.

Sport as a psychosocial management tool

While it is essential to understand the challenges transplant athletes face during RTS, clinicians should emphasize the benefits of participating and competing in sporting activities. Sports could improve physical, psychological, and social outcomes, and individuals returning to activity should be aware of these associated benefits. In addition, gaining an awareness of the psychosocial mechanisms may help clinicians advise on and support individuals in their RTS while promoting sport as a useful psychosocial tool for managing illness and navigating the life course post-transplant. Furthermore, in the context of the COVID-19 pandemic, the psychosocial mechanisms associated with participating in sport have become increasingly more critical given the mental health concerns of social isolation.

Gratitude

Transplant athletes feel a sense of gratitude and sometimes guilt about their survival, influencing their behaviors and motivations when participating in sport. Individuals may feel obligated to give something back after receiving the ‘gift of life’(11). To acknowledge the donor’s sacrifice, individuals may feel the need to prove their worthiness when RTS. Furthermore, participating in sport offers transplant recipients a way of embodying the positive self-management practices that promote health, leading them to feel obligated to continue participating. Transplant athletes who participate in the Transplant Games events may feel that taking part offers an opportunity for these beliefs to be confirmed. This may accentuate their gratuitous behavior when competing with other athletes who feel the same. In this way, participating in sport is a meaningful experience that offers individuals an opportunity to fulfill an obligation to express gratitude and give something back by promoting organ donation and healthy living.

Sense of belonging and closeness

Sport may offer an immediate bond between transplant athletes as it promotes an opportunity for individuals to come together and share experiences of their illness, transplant, and their RTS journeys(11). Furthermore, transplant athletes may experience a sense of community as they work towards maintaining and managing their health, transplant, and sporting ambitions. For transplant athletes, a shared identity exists that promotes the strength of these bonds and enables a sense of belonging. This identity is intertwined with their transplant and sport, offering multiple reasons and motivations to form close relationships. A sense of belonging and closeness also promotes collective confidence in their ability to perform. In this way, seeing others performing may provide inspiration and hope in the longevity of their health and sports commitment.

Increased support network

Another psychosocial mechanism of taking part in sports is the associated social benefits. Sports participation facilitates social support networks essential for their self-management outcomes post-transplant. That is, distress or trauma such as severe illness or injury often impacts more than the individual themselves; it impacts close network members such as family and friends. Family and friends may experience concern for their loved ones and become anxious or overprotective, thus affecting their support. Taking part in sports offers transplant athletes the opportunity to discuss their health and RTS concerns with others who have similar experiences. That way, they reduce the burden on their close family and or friends when seeking advice and support. Furthermore, transplant athletes can buffer the negative experiences of their intimate relationships by participating in sports as these relationships are often too close to offer support when discussing health concerns or sporting capabilities post-transplant.

Conclusion

Transplant athletes face unique challenges when they RTS, and these life-long health challenges constantly ebb and flow. However, sport offers individuals an opportunity to fulfill an obligation, give something back, and express their gratitude for their transplant. In doing so, sport becomes a meaningful experience that creates a sense of belonging, closeness, and increased socialization. Therefore, clinicians and practitioners should promote sport and consider events such as the Transplant Games to help individuals reflect on the meaning of the activity and provide opportunities to bring new relationships into their social support network.

References

  1. Qual Health Research. 2021; 31(2), 385-398
  2. Inter Review for the Soc of Sport. 2021; 1012690220979202
  3. World J of Hepatology. 2015; 7(10), 1355–1368.
  4. Transplant International. 2015; 28(1), 10–21
  5. Pediatric Nephrology. 2016; 31(12), 2235–2247
  6. British J of Sports Med. 1990; 24(2), 130.
  7. Scand J of Med & Sci in Sports. 1999; 1, 1–14.
  8. 2013; 143(3), 744–750.
  9. Liver Transplantation. 2016; 22(11), 1544–1553.
  10. Disability and Rehab. 2017; 39(19), 1976-1982.
  11. Bescoby, C. 2021. Doc Thesis.
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