Identity and Sport Participation Following Limb Loss: A Qualitative Study

Abstract

Background/Objective: Research indicates that sport is a useful avenue in rehabilitation for redeveloping identity for people with a limb amputation. However, the available research focusses on Paralympians or elite athletes with disabilities. By contrast, this study aimed to explore the experience of sport participation and identity in lay members of the public who had undergone limb amputation. Methods: Semi-structured interviews took place with nine people who had undergone amputation and participated in sport. The interviews were recorded, transcribed, and analysed using interpretative phenomenological analysis. Results: Four themes were developed from the data: (1) enabling a feeling of normality and equality; (2) becoming a better person; (3) belonging and connection; and (4) experiencing and responding to the gaze of others. The findings highlight the role of sport in facilitating personal growth through a desire to help and inspire others. Conclusions: Rehabilitation professionals involved in care following amputation could offer person-centred therapies to those who may be reluctant to participate in sport in a way that makes use of a person’s values and facilitates personal growth.

1. Introduction

Rehabilitation following limb loss is managed by a multidisciplinary team (MDT) of various healthcare professionals, including physiotherapists, psychologists, prosthetists, occupational therapists, and nurses [1,2]. Psychological difficulties such as depression, anxiety and post-traumatic stress disorder (PTSD) often follow limb loss [3,4], and this can be accentuated in those who have higher levels of pain and are restricted in activity [5]. To enhance physical, psychological, and social functioning, physical activity is often used as part of rehabilitation following amputation [6,7].

Regular sport participation or physical activity has been found to have a positive impact on quality of life, health, and psychological wellbeing [8,9]. For individuals with physical disabilities, these benefits extend to helping reaffirm their ability and feel less disabled [10], accept their disability [11], build a positive body image [10,12], increase self-esteem [13], and is an opportunity to enrich their social life [14,15]. People with disabilities can take part in adapted sport amongst others who also have a disability, which has been found to provide a sense of belonging, commonality, and normality [16,17,18,19]. Alternatively, they can participate in sport alongside others without a disability. This has been reported to help people feel a diminished salience of their disability in integrated sporting environments [20].

Sport or physical activity participation rates in individuals with a lower limb amputation vary in the literature and range from 11% to 60% [21]. Differences in rates have also been reported between countries, with 32% being reported in the Netherlands [22] and 60% in the United States [23]. Additionally, 83% of individuals with limb loss report that they would like to take part in more physical activity and sport in the future [24], suggesting that there is a demand for supporting people with amputation in accessing sport.

For those who have good mobility, physical activity is important in maintaining use of their prosthesis [25]. Some individuals with limb loss restrict their levels of activity and participation in daily activities, and this has been found to correlate with pain, leading to psychological distress [5,26]. It has been reported that there are more barriers than motivators in taking up or maintaining an active lifestyle after amputation [27], and acceptance of limb loss, a daily routine incorporating activity, and self-confidence in trying new activities are important in facilitating activity [28].

After amputation, individuals may feel that they have become a different person [10] and have been described to go through a process of renegotiation or resistance in transitioning to a new disabled identity [29]. For individuals with an amputation, sport enables them to create a new identity of athletic and capable and reject the disabled identity [18]. Identity is described as ‘traits and characteristics, social relations, roles, and social group memberships that define who one is’ [30] (p. 69). Identity provides a lens to assist in meaning making and forms part of an individual’s self-concept, views on their personality, and beliefs about themselves. It is described as an important part of psychological wellbeing, assisting people in living a meaningful life [31]. It has been found that when people participate in adapted athletic activities, they are less focused on their disability, giving them freedom to express themselves and thus focus more on the process of identity development [32]. Sport participation has been found to assist individuals with limb loss to feel ‘normal’ [19,33]; however, much of the research that exists concerns Paralympians or elite athletes with disabilities [34,35]. While illuminating, these studies provide detail regarding exceptional physical abilities rather than the abilities that characterise most individuals with limb loss.

The above research indicates that sport participation is a useful avenue in redeveloping identity for people with a limb amputation. However, while research exists regarding sport participation and disability, including some individuals with limb loss [18,19], there is a lack of research focusing solely on the experience of identity development or reconstruction for people who have undergone amputation and participate in sport and how this could help inform rehabilitation. Qualitative approaches can be particularly amenable to aiding an understanding of experiences that are ‘in flux, [and] negotiated within particular contexts or personal and social relationships’ and as a result ‘health and disability researchers have begun to use qualitative research methods to identify what the meanings of ill health and disability are from the point of view of those concerned’ [36] (p. 1134). Given these considerations, the present study set out to explore the meaning and experience of sport participation and identity for people following limb loss in order to identify any implications for rehabilitation.

2. Materials and Methods

2.1. Design

The present study focused on the lived experiences of people who had undergone amputation and engaged in sport; therefore, a qualitative methodology was most appropriate. Semi-structured interviews were used to elicit participants’ experiences, and data were analysed using interpretative phenomenological analysis (IPA) [37]. IPA is one of the most commonly used qualitative methodologies in physical and mental health research [38,39]. It was chosen as the most appropriate approach to address the research aims due to its theoretical and philosophical underpinnings of phenomenology, hermeneutics, and idiography [37]. IPA allows for the collection of detailed individual first-person accounts of research concern and aims to explore participants’ lived experiences (phenomenology) of a phenomenon and how they make sense of it [39]. Through interpretation of data (hermeneutics), each individual’s (idiography) experience of limb loss and sport participation, and what this means in terms of their identity, can be identified for commonalities and divergences with other participants.

2.2. Sampling and Participants

Due to the idiographic focus of the approach and the time-intensive analysis of individual cases, IPA studies typically involve small, homogenous samples ranging between four and ten participants [37]. IPA uses a purposive sampling approach, meaning the individuals recruited possess characteristics that make them the most appropriate group of people to explore the research aims [40]. Although the demographics of participants in this study vary, they are a homogenous group in that they all share the lived experience of limb amputation and have made the decision to engage in sport. This fits with the central focus of the study, which is the experiences of people who have undergone a limb amputation in adulthood and participate in sport.

Individuals were eligible to participate if they (a) experienced amputation of one or more limb(s) in adulthood (eighteen years or older), (b) after amputation they engaged in sport and were currently engaged in this, (c) were English speaking, and (d) were able to take part in a video or telephone interview. Recruitment took part during the COVID-19 pandemic when government restrictions and health and safety considerations meant that interviews could not be conducted face to face.

Participants were recruited online via disability sport groups and charities (e.g., Limbs4life, LimbPower, Blesma) (one participant was recruited in this way), via social media (Twitter/X, amputee or adapted sport groups/forums on Facebook and Reddit) (seven participants were recruited in this way), and via snowball sampling (some participants informed other people they knew who might be eligible) (one participant was recruited via this method). Therefore, a total of nine participants (four female, five male), aged 22 to 62 (mean 46), took part in the study. Time since amputation ranged from six months to forty years (mean 13.6 years). Five participants were from the UK, three were from the US, and one was from Australia. They took part in a range of different sports, such as swimming, sit skiing, cycling, and football. Demographic details and further details on the nature of their amputation and sport are presented in

Table 1. Participant Demographics.

Pseudonym	Age	Gender	Sport	Years Participated in Sport	Limb Amputated	Years Since Amputation	Country	Interview Method
Mary	59	F	Mountain biking	13	Left leg, below knee	40	Australia	Video
Chris	42	M	Sit skiing Mountain biking	2 5	Left leg, below knee	5	US	Video
Gary	27	M	Judo, obstacle courses	4	Right Leg, below knee	5	UK	Telephone
Bob	62	M	Swimming Cycling	20–25 10–15	Right leg, below knee Right arm, above elbow	35	UK	Telephone
Frances	55	F	Swimming	2	Right leg, above knee	2	UK	Video
Mike	51	M	Cycling	5	Left leg above knee	15	US	Telephone
Harry	22	M	Football	4	Right arm, above elbow	4	UK	Video
Carol	58	F	Swimming	15.5	Left leg, hind quarter	16	UK	Video
Jessica	40	F	Horse riding	36	Left leg, below knee	0.5	US	Video

.

2.3. Data Collection

Data were collected and analysed by the first author (‘researcher’ henceforth). Potential participants expressed interest by contacting the researcher via email. They were then emailed a copy of the participant information sheet, invited to ask questions, and the researcher checked that they met the inclusion criteria. Participants were asked their preference for interview format with a choice of video call or telephone call, and an interview was arranged at a mutually convenient time. Six participants opted to take part via video call, and three took part via phone call. At the beginning of each interview, the researcher checked that the participant had read the participant information sheet, and the participant was invited to ask any questions again. Due to the remote nature of the interviews, consent was gained verbally by the researcher reading the consent form and asking the participant to state that they agreed with each point and then giving overall consent.

A semi-structured interview schedule (see Supplementary Materials S1) was developed using existing research in the area of sport, disabilities, and identity [18,19] and in collaboration with the research team, who together had expertise in amputation and prosthesis use, health psychology, clinical psychology, and qualitative research. Questions aimed to elicit various salient aspects of their experiences of limb loss and sport, ranging from their initial experiences of amputation and the challenges in adapting to life after limb loss, to the decision process in taking up sport and if the way they saw themselves had altered since participating in sport.

The schedule contained questions that fell into four broad areas. Demographic information included questions focused on collecting additional information such as which limb was amputated and the sport the participant was involved in (e.g., Before we start the interview could you briefly tell me the nature of your limb amputation, and how old you were when it happened?). Limb loss questions focused on participants’ experiences and the challenges of amputation (e.g., What were the main challenges in adapting to life after limb loss?). Sport participation questions focused on how they made the decision to take up sport and the initial experiences of doing this (e.g., What was the process of deciding to take up sport after limb loss?). Finally, questions on identity aimed to explore how the participant saw themselves and if this was altered following amputation and sport participation (e.g., Did participating in sport impact on how you saw yourself?).

The interview schedule was used to guide the conversation to allow exploration of the research question. The researcher also facilitated the participant to discuss what was important to them, and at the end of the interview asked them if they had any thoughts relating to amputation, sport, and identity that had not already been covered in case they had important reflections that were missed. The interview length ranged from 40 to 83 min (mean 57 min). The interviews were transcribed verbatim with identifying information removed and pseudonyms used. Following the interview, participants were given the opportunity to ask the researcher any questions. After the interview, the participants were sent a copy of the participant debrief sheet containing contact information of charities and organisations that offer emotional or practical support in the event the interview had stirred up difficult emotions.

2.4. Data Analysis

IPA was used to analyse the data. Although IPA has a number of defining characteristics, there is no one prescriptive method of conducting IPA [41]. For the present study, the guide to conducting IPA by Murray and Wilde was followed because of the thorough audit trail it provides [42]. To retain the idiographic focus of the research, transcripts were analysed consecutively and, in accordance with this approach, the analysis was ‘bracketed’ or ‘held in abeyance’ between each transcript. Firstly, a participant’s transcript was read several times to aid familiarisation with the content. Next, initial codes were generated line-by-line describing the participant’s experiences and sense making. Once complete for the transcript, codes that shared common elements were grouped together into distinct themes. A short interpretive narrative was written for each theme that encompassed the participant’s experiences, meaning making and researcher interpretations that had been grouped together, and a title was assigned that summarised the narrative. Once this had been completed for each participant, the final stage took place whereby all themes across the sample were synthesised, noting converges and divergences. This resulted a final set of themes that reflected an understanding of sport participation, identity, amputation, and sense making that people assigned to this, and a narrative summary was produced for each theme. The final themes are supported by an appropriate amount of data as per Smith’s [39] guidelines, which state that for an IPA study with a sample containing more than eight participants, each theme must contain extracts from at least three participants and state the prevalence of participants. Throughout the process of analysis, the third author audited each step of the analysis to ensure the IPA method was followed appropriately. Recommendations such as combining elements of some themes into others were incorporated.

2.5. Reflexivity

IPA involves a process of double hermeneutics, in which participants attempt to make sense of their own experiences, which is then interpreted by the researcher. It is important that the researcher is aware of and able to bracket their assumptions and beliefs, as this can impact the interpretation [37]. Therefore, a core component of IPA is reflexivity. The researcher did not have a lived experience of limb amputation nor did they know anyone who had been through such experiences. Their knowledge and beliefs were therefore shaped via society and the media. With this in mind, the researcher completed a reflective journal to aid reflexivity, making notes during data collection of assumptions, and reflections before and after interviews. For example, the researcher reflected on their experiences of watching Paralympic athletes on television and how the athletes are often viewed as an inspiration. The researcher met regularly with the third author, a health psychologist with extensive experience in conducting interpretative phenomenological analysis, to help identify and bracket any presuppositions during data collection and analysis (for example, how comfortable someone with limb loss might be in speaking about their experiences with someone without a physical disability).

2.6. Ethical Considerations

The research was given ethical approval on 8 February 2021 by Lancaster University Faculty of Health and Medicine’s Research Ethics Committee (FHMREC reference: FHMREC20176). Procedures for gaining consent and data storage were followed. Due to the nature of remote interviews, careful consideration was given to how to manage distress during the interview. A plan was developed, and it was agreed to discuss with each participant prior to the interview how distress would be managed, for example, whether there was someone they could speak to. During the interviews, no participants appeared distressed; however, sources of country-specific organisations and charities that could provide emotional support (including the Samaritans, Mental Health America, and the Limbless Association) were provided on a debrief sheet following the research interview. No participants requested to remove their data or withdrew from the study. All data excerpts involved the use of pseudonyms to protect each participant’s identity.

3. Results

3.1. Theme 1: Enabling a Feeling of Normality and Equality

All participants described how taking part in sport enabled them to feel ‘normal’, equal to others, or helped them to regain aspects of their life they had prior to amputation. However, this process differed between participants: some took part in sport with non-disabled people (Mary, Carol, Chris, and Jessica), one took part with other amputees (Harry), and some did a combination of taking part alongside people with and without a disability (Bob, Mike, Gary, and Frances).

Mary, who cycled with non-disabled people, did not feel disabled when she took part: “I think competing with able bodied people…makes me think that I’m not disabled”. This feeling was shared by other participants who felt that sport was a useful tool in facilitating a feeling of equality and normality, especially as they were able to keep up with others. Mike described his feelings of normality when cycling versus walking:

…It’s just something I can do that I seem totally normal at, you know. I don’t have any special equipment.…I can pedal with two legs just like a normal guy…I can walk normal but you know, I don’t know it’s hard to explain, walking around, I’m still an amputee, but when I get on the bicycle I’m a bicyclist. I don’t consider myself an amputee bicyclist, I’m just a cyclist.

Taking part with people without a disability could also help individuals with limb loss feel equal and no different to others if they are treated the same and do not receive special treatment. Bob and Carol both experienced this in their cycling and swimming groups, and Bob reflected that it made him feel good. However, competing against non-disabled people could result in conflicting emotions. For example, Gary expressed pride at being able to beat people who did not have a disability, but also a sense of frustration that it was not a fair competition:

I’m not as motivated sometimes because they are able-bodied competition, so you know you’re starting off and you’re already kind of on the back foot before you’ve even started, but I also really like for example the (race), I think I finished 7th…and every single person was able-bodied so there’s you know there’s a real sense of pride there.

Some participants described sport as enabling them to be themselves, confirm and strengthen their identity, and be something other than an amputee: “it made me feel good I was part of a group not just the amputee guy who comes along for work you know sits behind while the others have a good time” (Bob). Taking part in sport also assisted with this feeling, as it provided participants with a sense of their past self. For example, Chris had found a sport to replace basketball, which he was no longer able to play:

With sit skiing you can’t keep me off the mountain unless there’s like some serious problem, otherwise I’m going to find a way I’m going to get up there, and I haven’t had something like that since losing basketball.

The ability to take part in sport also reflected that life was continuing as normal and was no different despite having had an amputation. Harry, a member of an amputee football team, explained this as he reflected how his feelings had changed over time: “at first I was feeling sorry for myself…what’s going on, what’s gonna happen with my life. I see now I’m just continuing as normal, and now I’ve got just got a positive outlook on everything.” This view was also echoed and expanded on by Jessica, who saw being able to take part in horse riding again and achieve what she could prior to amputation as reassurance that life was heading in the right direction:

Like the first horse I rode other than my own and I was able to ask for certain movements and the horse responded appropriately maybe a little expressively, because I wasn’t quite sure what my leg was doing, it was like confirmation that I was on the right track and things were gonna be OK.

In summary, taking part in sport provided participants with a sense of normality and equality. This was achieved via taking part with non-disabled people or with people who also had a physical disability. Taking part in sport helped participants to feel ‘normal’, as they were able to achieve something non-disabled people could, or something they were able to do before amputation. In addition, this enabled them to be treated the same as others, allowed the maintenance of their pre-amputation identity, and helped them to view their life as continuing after amputation.

3.2. Theme 2: Becoming a Better Person

Participants recounted how their amputation and sport participation had facilitated personal growth. This included the development of new personal qualities and a desire to help others. Eight of the nine participants are represented in this theme.

Some felt that through their experiences of amputation and sport that they had developed positive qualities and become a better person: “I think I see myself as a better man than I was…I’m the same person, but enhanced, if that makes sense. I’m a lot more compassionate than I was before. More understanding” (Mike). Through playing football, Harry’s confidence increased, and he became more extraverted: “I’d say I’m outgoing. That’s probably. Yeah, erm I’d say I’m loud now, I’m loud because of it.” He felt that being affiliated with a well-known football club and the opportunities to play at stadiums around the country were fundamental in building his confidence: “[F]or me to say, obviously I play for [team], which is, it’s not your average team, is it? It’s a big club, and you say you play under there under that foundation it’s a confidence boost in itself.” Dealing with the challenges of life after amputation, such as pain and exhaustion, also helped participants to develop compassion and empathy for others: “I would say I’m definitely a lot more aware of what other people are experiencing, potentially more compassionate” (Jessica).

Some participants discussed their early experiences after amputation and reflected on the mental challenges they faced: “Main challenges apart from the obvious physical ones was mentally and emotionally. I just could not come to terms with what they’ve done” (Frances). Despite initial struggles, Frances found that swimming did not just help her physically but also emotionally, as it boosted her mood: “it helps you mentally… you actually feel so good that you’ve actually done it and it really, mentally, I think it really boosts you,” and this positive effect was also noticed by family.

Although amputation led to losses amongst some of the participants, such as job role and independence, amputation also led to personal gains: “for me the amputation has, for everything it’s taken away from me, it’s giving me something else. Whether, you know, empathy, humility, kind of forcing me out of my comfort zone” (Chris), suggesting loss of a limb as a sacrifice for gaining positive personal qualities. This increased empathy for others then led to a desire to help people in a similar situation. Some participants wanted to share their experiences and knowledge with the aim of improving the experience of sport for people with an amputation. Following his amputation, Chris spent time researching the most appropriate prosthetic to use for his type of amputation and sport. He was keen to combine his knowledge and experience of amputation and sport to help others: “by me figuring this out I can then go share this so that other people can figure it out and that kind of stuff.” These personal gains were also reflected by Mike, who received feedback from others after he helped them cycle “I’ve had a couple people send me videos of them being able to get back and ride on their bikes and they’re like ‘you helped me get, you helped me get back into life’, I think that’s cool.” Jessica even decided to train as a prosthetist after her experiences of pain and amputation and is keen to undergo further training: “I wanna make sure that I’m able to actually help people.”

Another way that some participants helped others was by inspiring others to take up sport: “I think I actually thrive on that, on the fact that I make people look at themselves and think ‘well if she can do it I can do it as well, why am I complaining’” (Mary). This inspiration was reciprocal, and Mary not only enjoyed inspiring others but also sought inspiration from other athletes with a disability: “I do get a lot of inspiration from other people that have had traumas in their life.” However, the feeling of being an inspiration was not appreciated by all:

I don’t want to be an inspiration, but I kind of see I’ve inspired a lot of people via some Facebook pages with videos on how to get started on cycling and riding stuff, I think it’s, it’s kind of cool that I can help people learn to ride. (Mike)

To summarise, this theme shows that participants developed positive personal qualities, such as compassion and empathy, through their amputation and felt that it has resulted in them becoming better people. This led to a desire to help others, which gave them satisfaction, motivation, and a new purpose in life.

3.3. Theme 3: Belonging and Connection

Alongside the sense of normality that participation in sport instilled, where this involved being part of a team or a group, participants felt a sense of belonging and connection to others. Seven of the nine participants contributed to this theme.

Being part of a group facilitated the development of friendships and broadened participants’ social networks, resulting in positive emotions, exemplified by Mary: “it gives me a beautiful social network…I just feel very loved and wanted and yeah appreciated.” Bob expanded his social network through taking part in sport, and for him it was the primary reason to get involved. The social element provided an incentive to exercise and is something to look forward to: “I thought I’d do something where there’s a social activity where you’re meeting other people, doing something where you can also have a chin wag afterwards.”

Being part of a group could be encouraging and help in overcoming fears related to sport. Mary described herself as a “naturally fearful person”; however, she was encouraged and helped by the people in her cycling group, and she also returned the support and encouragement to others: “they cheer you on for your goal, so you cheer them on for their goal, so it’s very reciprocal.” This helped to enhance the experience and encouraged her to continue cycling.

Being amongst others with a disability or amputation who understand the struggles of living with an amputation was valuable. It gave opportunities for learning and support and provided space to share experiences that could not be gained from spending time with non-disabled people:

They understand your struggle, how you adapt to things, and they’ll obviously give you advice. For example, there was one guy, plays for [team name], he taught me how to do shoelaces, just little bits like that, you can just bounce off each other I suppose. (Harry)

This ability to connect with others helped participants to not feel alone and had a positive impact on their mental health. Being part of a group offered a feeling of belonging and reassurance that they were not alone: “you know there are other people out there that have their own struggles and you feel a part of something when you are in a group I guess” (Frances). Despite the differences in type or level of amputation, Frances felt that connecting with others who had undergone an amputation was important and likened it to therapy:

I’ve always thought there’s no better therapy than one amputee talking to another because you just get it, you know what it’s like. And even if it’s not the same leg, same height, you know if it’s a bilateral, above knee, you still, you’re still missing a limb.

For some participants, simply being around other individuals with limb loss or a disability served as a source of inspiration and reassurance, which had a knock-on effect on daily life: “you can get on with daily activities because a lot of other lads do it so there’s no reason why you can’t do it” (Harry).

Some participants acknowledged how support from others, either within sporting groups or from friends and family, was instrumental in building confidence. Amongst the swimmers, support from others was key in building confidence in the water. For example, Carol’s friends helped her with the practical side of accessing the pool, family provided encouragement, and swimming instructors provided her with tips and direction. This all helped in the building of her confidence and eventually she felt able to go swimming without assistance: “I felt confident enough to go in the pool on my own and turn up on my own, get dressed on my own, do everything on my own.”

Being able to take part in sport and activities with friends and family was also important to some participants. Sit skiing was a sport in which Chris was able to keep up with his friends and children and meant he was no longer “holding everybody back,” which made it a much more enjoyable experience. Similarly, Mike introduced his wife to cycling and it was now something they did to spend quality time together. Mary also met her partner through cycling, and they continue to take part in events together. Cycling was a way they can have fun and show affection to one another:

He cycles in his event so he’ll pass me and then we wave kisses to each other and it’s always ‘aw there goes my man’ and he goes ‘there you go my precious girl’ so yeah it’s really just good fun.

To summarise, being part of a sporting group following amputation provided a feeling of belonging. The social side of being part of a group provided opportunities to learn from others, for example, daily living tips, and gain support and encouragement. For some participants, sharing their sport with family and friends was a useful way to spend quality time together and fostered feelings of connection.

3.4. Theme 4: Experiencing and Responding to the Gaze of Others

The visibility of limb loss when engaging in sport was an important aspect of participants’ experiences. While some enjoyed being seen by others because they thrived on the positive feedback and inspiring people, others were uncomfortable and did not like the labels assigned to them by others. Some also found that the way they felt about being viewed had changed over time. This theme is made up of experiences from seven participants.

For most participants, taking part in sport resulted in their amputation being on show, and some found this difficult to begin with: “when I started I was a little bit embarrassed and I didn’t want people really looking at my leg… but now I’ve become like you know what this is me, almost flaunt it” (Mary).

Frances had similar feelings: “The first time I went there [swimming pool] I was just mortified that I was going down in a hoist, and I thought all eyes were on me, but now I don’t bat an eyelid.” Despite the fear of negative evaluation from others, Frances recognised the benefits and enjoyment she got from swimming and saw these as outweighing negative appraisals from others. She placed a high value on the activity of swimming and saw the negative judgements as a reasonable price to pay. She temporarily gave up her feelings of comfort to gain the positive effects of swimming:

…I can’t spend the rest of my life just sitting around not doing anything, I have to do something, and even if it means just for that short hour that somebody else notices that I have got an amputation, so if I was in a public pool, I just think that the gain is worth it. (Frances)

Harry described how he would initially avoid going out and wearing t-shirts that made his arm amputation more visible; however, becoming involved in amputee football instilled confidence in him:

…when I first had the amputation, I didn’t want to go out. But now I’m not afraid to go out and play sport with my say, just having a kick around with my friends in the park, I wouldn’t have done that. But now I’ve got the confidence to do that.

The level of exposure could also be helpful in reducing the stigma associated with people with a disability. Due to his multiple amputations and reliance on others, Bob often felt like he was “a burden on society”; however, by being welcomed into a club with accessible facilities, he felt he was shown a different side to how he was viewed by others: “it reduced that stigma of being disabled that you’re a hindrance that you’re a pain in the backside.”

Conversely, some participants enjoyed the exposure and visibility to others and the opportunity this brought to inspire others. Mary described a change in how she felt about others viewing her amputation and prosthetic, and over time she enjoyed the attention and admiration it brought:

I actually enjoy the, it sounds vein, but the attention because even though I’m last everybody cheers me as I come in because they all can see I’ve got a prosthetic so like ‘wow you can do it so what’s my excuse’, and I think I actually thrive on that. (Mary)

Others did not enjoy the increased amount of attention and status of being an inspiration. Gary described his conflicting feelings around this: “I think people now see me as this inspirational person, who’s just an inspiration because they do a lot of sport, which in some respect is quite a nice feeling but it does get a bit tiresome sometimes.”

Some participants felt that they were predominantly viewed as an amputee rather than as an athlete: “I’m getting viewed as like an amputee as opposed to like, hey, there’s that girl and she can totally ride those difficult horses, which I can still do, just there’s a little bit of leg missing” (Jessica). This differed to Carol’s experiences of being viewed for her abilities and given nicknames such as “the mermaid.” This had a positive impact on her confidence as she felt she was being recognised for something she could do well.

Participating in sport was a useful way to influence others’ opinions of people with an amputation. This was especially important for Jessica who felt she was looked at “with distain” as limb loss could be associated with diabetes and an unhealthy lifestyle: “sport is extremely empowering, and it gives us the ability to demonstrate our strength without having to say anything.”

To conclude, the gains obtained from taking part can outweigh the possible uncomfortable feelings of being viewed by others, and participants’ feelings around this changed over time as they became more confident. In addition, some participants used sport to display their capabilities to show others what they could achieve.

4. Discussion

The aim of this study was to explore the meaning and experience of sport participation and identity for people following limb loss in order to identify implications for rehabilitation. Using interpretative phenomenological analysis (IPA), four main themes were identified: enabling a feeling of normality and equality, becoming a better person, belonging and connection, and experiencing and responding to the gaze of others.

The feeling of normality and equality when participating in sport was described by all participants. Taking part in sport provided participants with continuity between past and current identities, as it helped them to feel equal to others, not disabled, or someone other than an amputee. Identity can often be fractured through illness [43] and experiencing bodily losses can lead to ‘feelings of estrangement’ from the past body [44] (p. 662). However, the results from the current study suggest how sport can ameliorate this disruption by providing an environment where one can connect with their body. Building on the feeling of normality and equality that sport participation could imbue, participants also recounted how this minimised a disabled identity. Sport participation enabled participants to make positive comparisons with their past self but also with current peers without a disability, and consequently reject the disabled or amputee identity. These findings extend insights from previous research, such as studies where a participant described forgetting that they were an amputee when participating in sport [33], and where the majority of interviewees reported that taking part in sport provided them with the feeling of normalcy and equality with peers [19].

Almost all participants mentioned how amputation and sport participation facilitated personal growth, such as becoming a better person and having a new desire to help and inspire others. They felt that they had become more empathic, compassionate, and understanding. Some used these qualities to help others in a similar situation by encouraging them to take part in sport, helping people locate the most appropriate prosthesis, and taking part in sport in a way that they would be visible to others and inspire them. This has similarities to ‘post-traumatic growth’, which is described as a positive psychological change resulting from challenging life events [45,46]. These life events challenge the way an individual understands the world and their place in it [47]. Therefore, growth does not occur directly via trauma but through the difficulties an individual experiences with making sense of their new reality. In relation to limb loss, it has been found that providing space to cognitively process the trauma and social, emotional, and practical support can facilitate post-traumatic growth [48]. This growth has also been found to facilitate psychological adjustment amongst individuals with limb loss [49]. The role of physical activity has been found to aid individuals in post-traumatic growth following illness and disability [50,51], as it helps in the understanding and processing of trauma, and allows individuals to take risks and test boundaries and their psychical capabilities.

Connecting with others and a sense of belonging from being part of a team or group provided participants with a social network to seek support and friendship. For some, this helped to build confidence in their sport, and for others, this extended to everyday situations that people with limb loss must learn to navigate. Experiences with others who have had similar experiences can assist in identification with others. In addition, taking part in group sport with other people with disabilities is reported to provide a sense of belonging, which can help to develop an athletic identity and sense of self, in addition to providing a sense of belonging, commonality, and normality [16,17,18,19]. The finding of belonging and connection is complemented by existing research: being part of a team or group allows individuals to meet people with similar experiences and also helps them to feel a part of the wider community as people watch them play and support them [52].

The gaze of others when participating in sport was important to most participants. Some respondents enjoyed being viewed and felt sport participation was a useful way of displaying their capabilities, whilst others felt uncomfortable being viewed and felt they were judged negatively. Taking part in sport enabled individuals with limb loss to disprove beliefs and show others, and themselves, that they were able to do something non-disabled people can do [53] and show their strength and abilities [17,54]. In addition, remaining physically active can allow people to not be seen as someone with a disability [55]. Participant reports of internalised stigma changed after becoming involved in sport. This had similarities to existing research that found that taking part in amputee football allowed individuals to be seen positively [52] and with research that indicated engaging in physical activity can help individuals to manage the stigma associated with physical disability [56].

4.1. Clinical Implications

The findings of this study highlight the positive effects that taking part in sport can have on identity for people living with limb loss and have important implications for the rehabilitation process following amputation. As physical activity is a core part of rehabilitation following amputation for the maintenance of prosthesis use and to enhance physical functioning [6,7,25], individuals with an amputation could be encouraged to participate in sport. This could provide both physical gains and positively impact identity and sense of self. Increased understanding of the role that sport plays in instilling a feeling of normality, equality, and reduced stigma may be used to target sport and rehabilitation interventions to vulnerable groups (for example, individuals with a poor view of disability or individuals with low self-worth). It is important that technical, social, and personal barriers and facilitators [25] are considered when encouraging people with limb loss to participate in sport. This is particularly important considering the large number of individuals with limb loss who would like to take part in more physical activity and sport in the future [24].

The theme ‘becoming a better person’ shows how taking part in sport leads to values such as helping others and indicates the potential utility of particular psychological therapies. Acceptance and Commitment Therapy (ACT) [57], which adopts a person-centred approach, assists people to identify and live according to their values. This may be helpful for some people with an amputation. For example, for many participants, helping others was important to them, and ACT can be useful in helping people continue to live in line with their values despite disability. Existing research has reported the successful use of ACT in assisting with difficulties following burn injury [58], and stroke [59], and diabetic neuropathy-related pain [60]. ACT may be useful in helping people who are unsure about taking up sport and could assist them in maintaining physical activity in a way that they can also be living towards their values. This could also be particularly helpful for people who have experienced a sense of loss following their amputation.

Given the findings that connecting with others who have also undergone amputation and helping people access sport was important to a number of participants, health professionals working with individuals with limb loss should consider the importance of sport in facilitating personal growth. Peer support has been reported to improve outcomes for individuals following amputation [61] and can provide the supporter with a sense of belonging, connection, hope and resilience [62]. Rehabilitation professionals could be involved in helping individuals with limb loss consider ways of supporting and mentoring others in their chosen sport or interest.

Psychological input as part of a multidisciplinary team (MDT) is recommended in professional guidelines regarding rehabilitation following amputation [1,2]. The findings of this research can be utilised by health professional involved in rehabilitation after limb loss to facilitate identity formation. Clinical and health psychologists, in particular, could provide individual support to those who are ambivalent or reluctant to take part in sport and could provide consultation and training to members of the MDT on communication techniques or motivational interviewing skills [63] to also help working with people who are ambivalent about sport. It is important that the MDT work together in providing joined up advice and personalised plans to match with individuals’ needs and abilities.

4.2. Strengths and Limitations

This study is unique in providing an in-depth understanding of the experiences of lay people, or non-professional sport competitors, with an amputation who take part in sport. An international sample was obtained with a relatively even split of males and females, thereby including a diverse set of experiences in the research. The use of video calls allowed the inclusion of participants based anywhere in the world, providing they met the inclusion criteria, increasing the chances of recruiting from a relatively small population.

Although there are strengths to the study, there are several limitations to be considered. While the sample was considered homogenous, there were some differences between participants, such as the time since amputation and reason for amputation. Although this allowed for a broad range of experiences to be discussed in the interviews, those who experienced amputation more recently may have been better able to remember and recall their experiences than those who had experienced amputation many years prior.

Participants were self-selected, so it is possible that only those who had positive experiences with sport and were confident in their identity opted to take part. Most participants who took part were recruited through social media from amputation support groups or amputee sport groups. It is possible that people who do not like to identify as being ‘an amputee’ avoid such groups and so the study may be missing the experiences of these individuals. Some participants preferred to participate in sport amongst other non-disabled people; therefore, there may be other individuals like this who were not exposed to the recruitment advert and so could not have taken part. Those recruited through amputee support groups may have had a greater need for social support and experienced difficulties following their amputation and so the study may not represent those who did not seek support. However, a benefit of the recruitment method is that it was advertised in various places and one participant was recruited through word of mouth from another participant, allowing people with different experiences and members of different groups and social media preferences to take part.

Finally, given the small number of participants in this study, the findings are not generalisable. Rather, with IPA the aim is to provide a concerted and detailed examination of experiential phenomena. However, as findings accumulate and reoccur with other populations and in different contexts, more certainty can be expressed regarding the universality of patterns in the results that are identified.

4.3. Future Research

Future research adopting a longitudinal approach would be valuable in aiding an understanding of the role of sport in the rehabilitation of people following limb loss over time. Similarly, given the Western-centric focus of much of the research on limb loss, and the use of largely white samples, research with participants from more diverse cultural backgrounds, ethnicities, or countries would be helpful in extending the evidence base concerning identity development and sport following amputation. Finally, the present research has focused on adults and so people who had lost a limb during childhood were excluded. Children and adolescents who are born with limb difference or lose a limb early in life would offer a valuable under-researched group where sport participation and identity could be explored further, particularly as childhood and adolescence are important life periods for identity formation.

5. Conclusions

This study used a qualitative research design to explore the lived experiences of people who had undergone limb amputation and participated in sport and the impact of this participation on their identity. The findings demonstrate the various ways sport can facilitate identity reconstruction following amputation and have important implications for the exploration of sport during rehabilitation and beyond. Health and clinical psychologists can assist by helping individuals to live according to their values, allowing them to regain and strengthen their identity. Taking part in sport can be beneficial in this process as it can allow individuals to connect with others, help people, and feel a sense of normality. Psychologists can also assist individuals in navigating feelings associated with the gaze of others and internalised stigma. The study also highlights areas for further research.