Common attributes in retired professional cricketers that may enhance or hinder quality of life after retirement: a qualitative study

Objectives Retired professional cricketers shared unique experiences and may possess specific psychological attributes with potential to influence quality of life (QOL). Additionally, pain and osteoarthritis can be common in retired athletes which may negatively impact QOL. However, QOL in retired athletes is poorly understood. This study explores the following questions from the personal perspective of retired cricketers: How do retired cricketers perceive and experience musculoskeletal pain and function in daily life? Are there any psychological attributes that might enhance or hinder retired cricketers’ QOL? Design A qualitative study using semistructured interviews, which were subject to inductive, thematic analysis. A data-driven, iterative approach to data coding was employed. Setting All participants had lived and played professional cricket in the UK and were living in the UK or abroad at the time of interview. Participants Eighteen male participants, aged a mean 57±11 (range 34–77) years had played professional cricket for a mean 12±7 seasons and had been retired from professional cricket on average 23±9 years. Results Fifteen participants reported pain or joint difficulties and all but one was satisfied with their QOL. Most retired cricketers reflected on experiences during their cricket career that may be associated with the psychological attributes that these individuals shared, including resilience and a positive attitude. Additional attributes included a high sense of body awareness, an ability to self-manage pain and adapt lifestyle choices to accommodate physical limitations. Participants felt fortunate and proud to have played professional cricket, which may have further contributed to the high QOL in this group of retired cricketers. Conclusions Most retired cricketers in this study were living with pain or joint difficulties. Despite this, all but one was satisfied or very satisfied with their QOL. This may be partly explained by the positive psychological attributes that these retired cricketers shared.

Thank you for asking me to review this paper. I feel there is a lot of merit to this paper; it highlights novel findings not previously described and uses sound methodology to collect the data. I have made a few minor comments below. Introduction While I feel the introduction includes all the necessary information to set the scene for the study I feel that a number of themes are discussed interchangeably in a single paragraph and that these could be grouped better to make the point. The 2nd paragraph described the psychological attributes of cricketers during play, the impact of retirement on psychology, QOL to OA and a cricketer"s ability to deal with pain in retirement all in 1 paragraph. The flow of the introduction would be better if concepts were explained more fully and grouped together. Page 6, line 37; The primary aim is reported to explore physical activity after retirement. However, this would appear to be the primary aim of the larger study not this one. Please correct this to present the aims of this study. The main question of this study therefore appears to be twofold: 1. The influence of musculoskeletal pain in retired cricketers on their QOL. 2. The psychological attributes of retired cricketers that may influence their retirement quality of life. Methodology Page 7, line 36: You indicate that your participants were selected from a larger sample based on their answer to 2 questions on physical activity. You need to indicate that you chose equal numbers of participants from each group (this is only clarified later in the methodology). The inductive thematic approach used in this study has been well described.

Results
Results are clearly presented and well supported by appropriate quotes. It should be highlighted that the results are a combination of qualitative and quantitative analysis. The interview findings have been used to explain the findings of high musculoskeletal injury and pain and the high quality of life experienced by cricketers. Page 11, line 3: Please could clarify if this past history of injury was "ever" or pre/post retirement. Page 12, line 42L "Language used throughout the …" I feel the word language does not adequately explain how the investigators came to make the conclusions they did. This may be pedantic but I feel this is better explained by the process of identifying themes and whether these themes are reflected positively or negatively. Page 13, line 226: Does the 21 test matches described by Sam not make him identifiable. Page 14, line 53: Figure 1: This figure does not accurately describe what you have described in your results. As you point out in the discussion it is unclear whether a resilient person becomes a successful cricketer or the sport helps an individual develop resilience. Your figure suggests that the positive and negative experiences develop resilience which you cannot conclude from your study. No examples are given for positive experience like have been included for the negative experience. Positive experiences produce emotions (fortunate, proud etc) while the negative experiences produced a physical experience (pain and function). This doesn"t make sense. I feel this figure needs to be revised. Discussion Page 15, line 57: "…who took party in this study described many attributes…..". Demonstrated indicates a more measurable assessment of the attribute. Page 16, line 3: "…greater proportion of retired, professional cricketers…". Page 16, line 10: "QOL outcome measures are driven influenced by pain and physical impairment…". "Driven by" indicates they are the sole determinants of QOL. Success, money, etc would surely influence QOL too. Page 16, line 34: "…the present study frequently described shared resilient attributes, this which was highlighted….". This sentence is very long. Please shorten it. Conclusion Appropriate.

Reviewer comment
The study is interesting and has a current issue. Abstract is appropriate Introduction OK Methods -Why the authors did not also use QOL subjective questionnaires?
1.1 Author response We agree that QOL questionnaires would have provided additional information that could have been a useful supplement to the qualitative interviews. However, assessing QOL was not an aim of the larger cross-sectional study from which participants were recruited and consequently validated measures of QOL were not included in the cross-sectional questionnaire design.

Author action
No action taken.

Reviewer comment
The sample is short and an author interview is a vies.

Author response
We believe the decision to perform 18 interviews was appropriate. The decision to cease recruitment at 18 interviews was supported by data saturation being achieved by the 14th interview. This was further confirmed by an additional four interviews that were carried out after data saturation, where no new themes emerged.

Author action
No action taken.

Reviewer comment
Some important papers in that theme were not cited by the authors: 1.3 Author action p5 Lines 6-8 After retirement, athletes are at increased risk of developing osteoarthritis, predominately due to a history of sport-related injury, and this can result in pain and activity limitations.3-7 p16. Lines 295-303: Retired professional footballers with osteoarthritis reported worse health-related QOL compared with retired footballers without osteoarthritis.22 However, most conventional QOL outcome measures (including the EQ-5D used in the study of retired footballers22) are influenced by pain and physical impairment, where the presence of pain and physical disability will result in a reduced QOL score, irrespective of the impact of pain or disability upon the individual.23 ************************* Reviewer: 2 comments ************************* Thank you for asking me to review this paper. I feel there is a lot of merit to this paper; it highlights novel findings not previously described and uses sound methodology to collect the data. I have made a few minor comments below.

Reviewer comment
Introduction While I feel the introduction includes all the necessary information to set the scene for the study I feel that a number of themes are discussed interchangeably in a single paragraph and that these could be grouped better to make the point. The 2nd paragraph described the psychological attributes of cricketers during play, the impact of retirement on psychology, QOL to OA and a cricketer"s ability to deal with pain in retirement all in 1 paragraph. The flow of the introduction would be better if concepts were explained more fully and grouped together.

Author response
Thank you for your constructive feedback. We have reformatted the introduction to improve the flow, as suggested.

Reviewer comment
Page 6, line 37; The primary aim is reported to explore physical activity after retirement. However, this would appear to be the primary aim of the larger study not this one. Please correct this to present the aims of this study. The main question of this study therefore appears to be twofold: 1. The influence of musculoskeletal pain in retired cricketers on their QOL.
2. The psychological attributes of retired cricketers that may influence their retirement quality of life.

Author response
We see how presenting the study aim in this way may create confusion. We do however, believe it is important to accurately report both the a priori aim of the overall qualitative study, and the specific aim of this paper. We have revised the wording and hope this improves clarity whilst still making a distinction between the overall study aim, and specific aim of this paper.

Author action
We have changed the wording to improve clarity: p6-7, Lines: 47-49: The a priori aim of this qualitative study was to explore physical activity after retirement from professional cricket. However, the study also captured participants" broader perspectives regarding QOL and prominent themes linking QOL to professional cricket emerged during the initial inductive analysis. This paper focuses on these emergent themes, which were explored while considering two sensitising questions: How do retired cricketers perceive and experience musculoskeletal pain and function in daily life? Are there any psychological attributes that might enhance or hinder retired cricketers" QOL? A complementary manuscript will address physical activity after retirement from professional cricket.

Reviewer comment Methodology
Page 7, line 36: You indicate that your participants were selected from a larger sample based on their answer to 2 questions on physical activity. You need to indicate that you chose equal numbers of participants from each group (this is only clarified later in the methodology). The inductive thematic approach used in this study has been well described.

Author response
Thank you for pointing this out, we have now included an additional sentence highlighting this.
2.3 Author action p8 Line 73-74: We aimed to include an equal number of participants from each of these groups.

Results
Results are clearly presented and well supported by appropriate quotes. It should be highlighted that the results are a combination of qualitative and quantitative analysis. The interview findings have been used to explain the findings of high musculoskeletal injury and pain and the high quality of life experienced by cricketers.

Author response
Although pain and osteoarthritis were assessed quantitatively in the larger cross-sectional study via questionnaire, this data did not contribute to the qualitative analysis. However, the cross-sectional data was used to describe the sample characteristics in Table 1. We realise this may not be clear, and have subsequently clarified this distinction in the methods section.

Author action
The following paragraph was added to the methods section: p10-11, Lines 138-143: Following qualitative analysis, responses to relevant questions collected as part of the cross-sectional study were used to describe the study sample (including osteoarthritis status, age, previous surgery and length of professional cricket career). Questionnaire data was cross-checked for accuracy with participants" narratives and if disparities were present (e.g. a participant reported no current joint pain on questionnaire but described experiencing current joint pain during the interview), participant narratives were considered more reliable.

Reviewer comment
Page 11, line 3: Please could clarify if this past history of injury was "ever" or pre/post retirement.

Author response
This has now been clarified.
2.5 Author action p11 Lines 155-157: More than two thirds (n=14, 78%) reported having ever had an injury that resulted in more than one month of reduced participation in exercise, training or sport.

Reviewer comment
Page 12, line 42L "Language used throughout the …" I feel the word language does not adequately explain how the investigators came to make the conclusions they did. This may be pedantic but I feel this is better explained by the process of identifying themes and whether these themes are reflected positively or negatively.

Author response
Indeed it was not merely the language used that demonstrated a high level of resilience amongst participants. To clarify, we have removed the reference to participant language.
2.6 Author action p12,  Attributes that appeared to enhance QOL in this sample of retired cricketers, included resilience and a positive attitude. Language used throughout the interviews highlighted that Almost all retiredcricketers in this study were resilient and had a positive attitude regarding pain and musculoskeletal impairment.

Reviewers comment
Page 13, line 226: Does the 21 test matches described by Sam not make him identifiable.

Authors response
We have decided to remove the start of the quote where reference to the number of test matches played is made. 2.7 Authors action p14 Line 242-244 "You just play the hand your dealt and I never think there"s any point having any regrets or bearing any grudges, it is what it is and you know I"ve had a great life out of it. …I"ve made plenty of rubbish decisions, but I wouldn"t change that fact, because all that failure and all that success has made me who I am and I"m quite happy being me now." 2.8 Reviewer comment a. Page 14, line 53: Figure 1: This figure does not accurately describe what you have described in your results. As you point out in the discussion it is unclear whether a resilient person becomes a successful cricketer or the sport helps an individual develop resilience. Your figure suggests that the positive and negative experiences develop resilience which you cannot conclude from your study. b. No examples are given for positive experience like have been included for the negative experience. c. Positive experiences produce emotions (fortunate, proud etc) while the negative experiences produced a physical experience (pain and function). This doesn"t make sense. I feel this figure needs to be revised.
2.8 Author response a. Thank you for this feedback. You are quite right, we cannot insinuate a causal relationship between positive/negative experiences while playing cricket, and psychological attributes such as resilience in professional cricketers. We only intended to highlight "potential" interactions between key themes as stated in the title. However, to ensure this is not misleading we have revised the figure to include question marks and have included a description of what this denotes in the figure legend. b. We have now included examples of positive experiences to improve consistency. c. With the inclusion of the arrow and question mark between experience and psychological attributes, the negative experience may result in physical (pain and limited function), behavioural (body awareness, self-management) and emotional/psychological (eg, resilience, mental toughness) impacts. If the arrow/question mark between negative experiences and psychological attributes was removed, than you are quite right that this would not make sense since negative experiences would impact only physical factors without having psychological consequences.
2.8 Author action p25 Figure 1. a. Question marks have been added to Figure 1 and a description of what this denotes has been added to the figure legend: "Question marks denote uncertainty surrounding the nature of the relationship between cricket-related experiences and psychological attributes common in successful cricketers, since individuals may possess these attributes prior to cricket participation" b. The examples given for "positive experiences" are as follows: success, comradery, pride, accomplishment c. No changes made since this has been addressed by adding question marks (see 2.8 a.)

Discussion
Page 15, line 57: "…who took party in this study described many attributes…..". Demonstrated indicates a more measurable assessment of the attribute.
2.9 Author response Thank you for this suggestion. We agree that demonstrated may not be an ideal word to use here. However, participants did not "describe" these attributes, rather, they "exhibited" them. Thus, we have replaced the word "demonstrated" with "exhibited." 2.9 Author action p16 line 306. "Demonstrated" has been replaced with "exhibited." 2.10 Reviewer comment Page 16, line 3: "…greater proportion of retired, professional cricketers…".
2.10 Author response We have replaced "proportion" with "number" 2.10 Author action p16 line 307: "It is possible that a greater number of retired-cricketers "flourish" in later life compared with the general population" 2.11 Reviewer comment Page 16, line 10: "QOL outcome measures are driven influenced by pain and physical impairment…". "Driven by" indicates they are the sole determinants of QOL. Success, money, etc would surely influence QOL too.

Author response
The majority of health related QOL measures, including the EQ-5D and SF-36, are largely influenced by the presence of pain or physical disability. Yet, they do not quantify the contribution of pain or physical disability to an individual"s QOL. Thus, if a person is physically disabled, the overall QOL score will be impaired. Nevertheless, we agree that "driven" may be somewhat misleading, and "influenced" would be more appropriate here.
2.11 Author action p16lines 311-314 However, most conventional QOL outcome measures (including the EQ-5D used in the study of retired footballers22) are influenced by pain and physical impairment, where the presence of pain and physical disability will result in a reduced QOL score, irrespective of the impact of pain or disability upon the individual.23

Reviewer comment
Page 16, line 34: "…the present study frequently described shared resilient attributes, this which was highlighted….". This sentence is very long. Please shorten it.

Conclusion
Appropriate.

Author response
This sentence has been shortened.
2.12 Author action p17 Line 352: Retired-cricketers in the present study shared resilient attributes, this was highlighted by their ability to maintain a positive attitude and adapt activity choices to effectively cope with fluctuations in pain and physical function. However, if other reviewers are satisfied I am happy to accept changes. I am happy that this is now publishable. 2 minor comments include: Page 12, line 192: "….in this study were resilient…". As resilience wasn"t measured directly it would be more accurate to say they describe characteristics akin to resilience. Page 15, line276: "… these individuals to possess, ….". Again, I think it would be more accurate to say these characteristics were described.

Author response
We would like to thank reviewer 2 for taking the time to critically appraise the manuscript and provide valuable comments and feedback. Your attention to detail is greatly appreciated.
In Figure 1, injury and surgery are described as "negative experiences". Injury and surgery are risk factors for developing chronic pain and osteoarthritis in later life, which a majority of participants reported and attributed to having played professional cricket. As described in the discussion, chronic pain and osteoarthritis have been associated with worse quality of life in other samples and general population groups. What is proposed in this figure, is that psychological attributes (including resilience, acknowledging limitations and self-management), as well as pride surrounding past accomplishments in cricket, may in part, negate the negative impacts of pain and osteoarthritis upon quality of life.

Author action
We have made small edits to the wording of Figure 1 legend to provide further clarity: p. 29 Green arrows and boxes represent factors with potential to positively impact quality of life; Red arrows and boxes represent factors with potential to negatively impact quality of life; A. Reflecting upon positive experiences in cricket and psychological attributes may positively impact quality of life following retirement from professional cricket; B. Reflecting upon positive experiences in cricket and psychological attributes may reduce the impact of pain, osteoarthritis and physical limitations on quality of life after retirement from professional cricket; Together, A. and B. provide one potential explanation for high quality of life despite a high prevalence of pain, osteoarthritis and physical limitations in this sample of retired professional cricketers; Question marks denote uncertainty surrounding the nature of the relationship between cricket-related experiences and psychological attributes common in successful cricketers, since individuals may possess these attributes prior to cricket participation 2.2 Reviewer comment 2 minor comments include: Page 12, line 192: "….in this study were resilient…". As resilience wasn"t measured directly it would be more accurate to say they describe characteristics akin to resilience. Page 15, line276: "… these individuals to possess, ….". Again, I think it would be more accurate to say these characteristics were described.

Author response
Thank you for drawing attention to this, we have made the following amendments: 2.2 Author action p13. "Almost all retired-cricketers in this study demonstrated characteristics and described experiences suggesting high levels of resilience and a positive attitude regarding pain and musculoskeletal impairment." p15. "...psychological attributes that these individuals may possess, including resilience, a positive attitude, heightened body awareness.."