Rehabilitation with intensive attention training early after acquired brain injury promotes better long-term status on health-related quality of life, daily activities, work ability and return to work.

OBJECTIVE: To describe long-term effects on activity, participation, and quality of life (i) at different post-injury starting time points of attention training and (ii) of two different types of rehabilitation with attention training in patients after stroke or traumatic brain injury; and to describe their functioning level. DESIGN: 2 years after rehabilitation intervention, comparisons were made in one cohort receiving attention training subacute (< 4 months) or post-acute (4-12 months) and in one cohort with two different training methods, a process-based and an activity-based method respectively. PATIENTS: 100 patients were recruited from our earlier RCT study. They had mild to moderate stroke or traumatic brain injury with relatively limited symptomatology, and all had moderate to severe attention impairment. METHODS: A questionnaire-based interview: EuroQol 5 dimensions, Occupational Gaps Questionnaire, Work Ability Index, self-assessed work status, self-reported employment conditions, sick leave, and experienced cognitive limitations in work performance. RESULTS: An advantage for patients receiving subacute attention training regarding daily activities, work ability and returning to work. CONCLUSION: The results indicate that subacute rehabilitation with attention training (< 4 months) is preferable compared to post-acute intervention (4-12 months). There were only minor differences between the training methods.

Predicting Outcome for Early Attention Training After Acquired Brain Injury.

Background: The training of impaired attention after acquired brain injury is central for successful reintegration in daily living, social, and working life. Using statistical process control, we found different improvement trajectories following attention training in a group of relatively homogeneous patients early after acquired brain injury (ABI). Objective: To examine the contribution of pre-injury factors and clinical characteristics to differences in outcome after early attention training. Materials and Methods: Data collected in a clinical trial comparing systematic attention training (APT) with activity-based attention training (ABAT) early after brain injury were reanalyzed. Results: Stroke patients (p = 0.004) with unifocal (p = 0.002) and right hemisphere lesions (p = 0.045), and those with higher mental flexibility (TMT 4) (p = 0.048) benefitted most from APT training. Cognitive reserve (p = 0.030) was associated with CHANGE and APT as the sole pre-injury factor. For TBI patients, there was no statistical difference between the two treatments. Conclusion: Our study identifies indiscernible factors predicting improvement after early attention training. APT is beneficial for patients with right-hemispheric stroke in an early recovery phase. Knowledge of prognostic factors, including the level of attention deficit, diagnosis, and injury characteristics, is vital to maximizing the efficiency of resource allocation and the effectiveness of rehabilitative interventions to enhance outcomes following stroke and TBI.

Comparison of attention process training and activity-based attention training after acquired brain injury: A randomized controlled study.

OBJECTIVES: To compare the effects of 2 interventions for attention deficits in people with acquired brain injury, Attention Process Training (APT) and Activity--based Attention Training (ABAT), on activity and participation. DESIGN: Randomized controlled study. PATIENTS: The study included 51 patients in out-patient rehabilitation 4-12 months after stroke or traumatic brain injury. METHODS: Intervention: 20 h of attention training. MEASUREMENTS: Assessment of Work Performance (AWP), Work Ability Index (WAI), Canadian Occupational Performance Measure (COPM), and Rating Scale of Attentional Behavior (RSAB). RESULTS: Between-group comparisons showed significantly improved process skills after APT: Mental Energy (p = 0.000, ES = 1.84), Knowledge (p = 0.003, ES = 1.78), Temporal Organization (p = 0.000, ES=1.43) and Adaptation (p = 0.001, ES = 1.59). For within-group comparisons significant improvement was found between pre- and post-measures for both groups on COPM Performance (APT: p = 0.001, ES=1.85; ABAT: p = 0.001, ES = 1.84) and Satisfaction (APT: p = 0.000, ES=1.92; ABAT: p = 0.000, ES = 2.40) and RSAB Total Score (ABAT: p = 0.027, ES = 0.81; APT: p = 0.007, ES = 1.03). CONCLUSION: We found significant differences favouring APT before ABAT for process skills (AWP). There were no discernible differences in global measures of activity between the 2 approaches: both groups improved significantly, as indicated by ES. The results of this study highlight the complexities of influencing behaviour on the level of body functions while measuring effects on activity.

Do quality of life, anxiety, depression and acceptance improve after interdisciplinary pain rehabilitation? A multicentre matched control study of acceptance and commitment therapy-based versus cognitive-behavioural therapy-based programmes.

OBJECTIVE: Interdisciplinary pain rehabilitation (IPR) usually employs a cognitive-behavioural therapeutic (CBT) approach. However, there is growing support for chronic pain treatments based on acceptance and commitment therapy (ACT). Most studies of ACT and CBT for chronic pain have evaluated their effects after psychological interventions, not after IPR. We compared the results of an ACT-based IPR programme with two CBT-based IPR programmes. METHODS: We used a retrospective multicentre pretest-posttest design with matched patient groups at three centres. Data were collected from the Swedish Quality Registry for Pain Rehabilitation before and after IPR participation. Participants completed the EQ-5D health-related quality of life questionnaire, the Chronic Pain Acceptance Questionnaire, (CPAQ) and the Hospital Anxiety and Depression Scale (HADS). Analyses were performed to compare the effects of the different interventions. RESULTS: Neither EQ-5D nor HADS depression scores were affected by the psychological approach used. The score changes on both CPAQ subscales (activity engagement and pain willingness) indicated significant improvements between admission and discharge at all centres. CONCLUSIONS: These findings indicate the effectiveness of using psychological approaches to manage chronic pain. Both CBT and ACT had a beneficial effect on most of the assessed health-related parameters.

Is a structured work task application for the assessment of work performance in a constructed environment, useful for patients with attention deficits?

BACKGROUND: The purpose of our study was to develop a Structured Work Task application for the Assessment of Work Performance for patients with attention deficits. MATERIAL AND METHODS: We developed a computer-based registration task titled the Attention-demanding Registration Task. It had a structured administrative procedure with additional scoring regarding time and accuracy, also linked to the original scoring of the Assessment of Work Performance. We evaluated the Attention-demanding Registration Task for content validity. Furthermore, we investigated it concerning sensitivity and specificity in patients with attention deficits due to acquired brain injury (n = 65) against a comparison group of healthy people (n = 47). RESULTS: Our investigation on content validity using the Assessment of Work Characteristics confirmed that the Attention-demanding Registration Task sets high demands on process skills, especially on energy, temporal organization, and adaptation. The Attention-demanding Registration Task showed high sensitivity and specificity in differing between patients with attention deficits and a healthy working group; nine out of ten participants were placed in the correct group. CONCLUSIONS: To assess work performance, the use of a Structured Work Task application, the Attention-demanding Registration Task, linked with the Assessment of Work Performance, proved to be sensitive to attention deficits.Implications for rehabilitationA Structured Work Task application for the Assessment of Work Performance was developed for use in people with attention deficits and showing a high degree of sensitivity and specificity.Linking performance time and accuracy to the Assessment of Work Performance scoring and providing a guide for linking task performance to the Assessment of Work Performance skills in addition to the usual observations performed, may increase scoring accuracy.Reference data for a comparison group of healthy subjects are provided.The use of the Attention demanding Registration Task, while using the Assessment of Work Performance within clinical practice ensures a more accurate description of process skills in performance.

Preliminary ICF core set for patients with myalgic encephalomyelitis/chronic fatigue syndrome in rehabilitation medicine.

OBJECTIVE: To create and evaluate a preliminary ICF Core Set for myalgic encephalomyelitis/chronic fatigue syndrome using a team-based approach. DESIGN: Observational study. SUBJECTS/PATIENTS: A total of 100 consecutive patients (mean age 45 years (standard deviation (SD) 9 years)) were assessed by a rehabilitation team and included in the study. METHODS: A preliminary International Classification of Functioning, Disability and Health (ICF) Core Set was created, based on literature studies, and on discussion forums between the team and the researchers. Patients were assessed by a rehabilitation medicine team regarding impairments in body function, activity limitations, and restrictions in participation. RESULTS: Clinical assessments of the component Body Functions found impairments in energy, fatigue, physical endurance, fatigability, sleep and pain in 82-100% of patients. At least half of the patients had impairments in higher cognitive functions, attention, and emotions, as well as sound and light hypersensitivity, general hyper-reactivity and thermoregulatory functions. For the component Activity/Participation, the most frequent limitations and restrictions were in doing housework (93%), assisting others (92%), acquisition of goods and services (90%), remunerative employment (87%), handling stressful situations (83%), preparing food (83%), recreation and leisure (82%), informal socializing (78%) and carrying out daily activities (77%). The most frequent degrees of impairments/limitations/restrictions assessed were light and moderate, except for remuneative employment, for which restrictions were severe. CONCLUSION: Using unconventional methods, this study sets out a preliminary ICF Core Set list for patients with myalgic encephalomyelitis/chronic fatigue syndrome. Further studies are required to improve and test this Core Set in myalgic encephalomyelitis/chronic fatigue syndrome populations.

Daily management of attention dysfunction two-four years after brain injury and early cognitive rehabilitation with attention process training: a qualitative study.

The evaluation of intensive cognitive training is usually based on neuropsychological tests and questionnaires. A study of the subjective experience of cognitive training would provide another type of valuable information concerning the effects of rehabilitation. We used grounded theory methods to explore the experience and management of attention dysfunction in daily life two-four years after brain injury. Data were collected by in-depth interviews of 14 adults with moderate-to-mild attention dysfunction after stroke or traumatic brain injury, and working part time or full time at the time of the interviews. The group received 20 hours of attention process training within the context of multidisciplinary rehabilitation early after brain injury. Data were analysed by open coding with constant comparison. The management of attention dysfunction was described by the informants as a dynamic process where strategies are continuously refined and flexibly adjusted as awareness and metacognitive knowledge increases. This process is regulated by situation-dependent factors. Attention process training might provide a suitable starting point for the identification of problem areas, improved specific goalsetting and stimulated self-training. The model describes the dynamic nature of the process, the ongoing struggle, self-training and search for feedback.

Beneficial effects of early attention process training after acquired brain injury: A randomized controlled trial.

BACKGROUND: Evaluation of outcome after intensive cognitive rehabilitation early after brain injury is complicated due to the ongoing biological recovery process. OBJECTIVE: To evaluate the efficacy of Attention Process Training early after acquired brain injury through time-series measurement with statistical process control. DESIGN: Randomized controlled trial. METHOD: Patients with acquired brain injury (n = 59) within 4 months' post-injury in interdisciplinary rehabilitation received an additional 20 h of attention training with Attention Process Training or with activity-based attention training. The primary outcome variable was Paced Auditory Serial Attention Test (PASAT) evaluated using statistical process control. RESULTS: Both groups improved (p < 0.001), although a higher number of patients improved with attention process training (χ2 (1, n = 59) = 5.93, p = 0.015) and the variability was significantly decreased. The Attention Process Training group maintained or improved performance at 6 months follow-up (χ2 (1, n = 51) = 6,847, p = 0.033). Attention Process Training required fewer intervention hours for improvement. Based on individual performance, 3 improvement trajectories were identified: stationary, steady, and rapid improvers. CONCLUSION: The results indicate that attention training is promising early after acquired brain injury and that Attention Process Training boosts functional improvement. Notably, in the present group of relatively homogeneous patients, 3 different trajectories were identified for recovery after acquired brain injury regardless of intervention.

Return to work after interdisciplinary pain rehabilitation: One- and two-year follow-up based on the Swedish Quality Registry for Pain rehabilitation.

OBJECTIVES: To investigate: (i) changes in sick-leave benefits from 1 year prior to multimodal rehabilitation to 1 and 2 years after rehabilitation; (ii) sex differences in sick leave; and (iii) the impact of policy changes on sick leave. METHODS: All patients undergoing multimodal rehabilitation registered in a national pain database for 2007-11 (n = 7,297) were linked to the Swedish Social Insurance Agency database. Sick leave was analysed in 3-month periods: T0: 1 year before rehabilitation; T1: before start; T2: 1 year after; and T3: 2 years after rehabilitation. Four sick-leave benefit categories were constructed: no sick leave, part-time sick leave, full-time sick leave, and full-time permanent sick leave. The individual change in sick-leave category at each time-period was analysed. RESULTS: Sick-leave benefits increased from T0 to T1 (p < 0.001) and decreased from T1 to T3 (p < 0.001). Reductions were significant for both men and women from T1 to T3, but men had less sick-leave benefits at T2 and T3. Positive changes in sick-leave benefits at T2 and T3 were found both prior to and after policy changes, with less sick-leave benefits after policy changes at all time-points. CONCLUSION: Multimodal rehabilitation may positively influence sick-leave benefits for patients with chronic pain, regardless of their sick-leave situation, sex or policy changes.

Statistical process control: A feasibility study of the application of time-series measurement in early neurorehabilitation after acquired brain injury.

BACKGROUND: Progress in early cognitive recovery after acquired brain injury is uneven and unpredictable, and thus the evaluation of rehabilitation is complex. The use of time-series measurements is susceptible to statistical change due to process variation. OBJECTIVE: To evaluate the feasibility of using a time-series method, statistical process control, in early cognitive rehabilitation. METHOD: Participants were 27 patients with acquired brain injury undergoing interdisciplinary rehabilitation of attention within 4 months post-injury. The outcome measure, the Paced Auditory Serial Addition Test, was analysed using statistical process control. RESULTS: Statistical process control identifies if and when change occurs in the process according to 3 patterns: rapid, steady or stationary performers. The statistical process control method was adjusted, in terms of constructing the baseline and the total number of measurement points, in order to measure a process in change. CONCLUSION: Statistical process control methodology is feasible for use in early cognitive rehabilitation, since it provides information about change in a process, thus enabling adjustment of the individual treatment response. Together with the results indicating discernible subgroups that respond differently to rehabilitation, statistical process control could be a valid tool in clinical decision-making. This study is a starting-point in understanding the rehabilitation process using a real-time-measurements approach.

The effect of sampling bias on generalizability in intervention trials after brain injury.

OBJECTIVE AND DESIGN: The first objective of this descriptive study was to explore the effect of strict inclusion and exclusion criteria on patient recruitment in cognitive rehabilitation; the second was to analyse the representativeness of study patients for all eligible stroke and traumatic brain injury patients referred to the department from September 2011 to November 2014. METHODS: The setting was multi-professional in- and outpatient brain injury rehabilitation in a university hospital. Participants were enrolled consecutively in acute (< 4 months) or sub-acute (4-12 months) phases of rehabilitation after injury. RESULTS: Nine-hundred-and-forty-four patients were screened. Many failed to meet the inclusion and exclusion criteria (acute phase = 90.5%; sub-acute phase = 85.3% excluded). The most frequent exclusion criteria were age and multiple co-morbidity. The most striking differences between eligible participants and non-participants were the latter's lower educational and occupational levels. CONCLUSION: Results indicate the need for a closer connection between selection criteria and study aims. Strict inclusion and exclusion criteria render the study population less representative and, thus, reduces generalizability. Data collection is prolonged. This study, instead, advocates the use of broad inclusion criteria and common data elements and the need to report data from the total patient population. Increased awareness of the participants' socioeconomic backgrounds is also needed when recruiting to research studies.

Work ability in patients with polymyositis and dermatomyositis: An explorative and descriptive study.

BACKGROUND: Polymyositis (PM) and dermatomyositis (DM) are rare, chronic inflammatory diseases leading to muscle weakness and low muscle endurance. The muscle weakness may lead to restrictions in daily activities and low health-related quality of life. OBJECTIVES: This study aimed to investigate the work situation, work ability, work-related risk factors, and influence of the physical and psycho-social work environment in patients with PM and DM. METHODS: Patients with PM/DM were assessed using the Work Ability Index (WAI), and the Work Environment Impact Scale (WEIS). RESULTS: Forty-eight patients (PM n = 25 and DM n = 23) participated (women/men: 29/19) with a mean age of 54 years (range 28-67 years, SD.10) and mean disease duration of nine years (SD.9). Forty-four percent worked full-time, 31% part-time and 25% were on full-time sick leave. More than 50% self-rated work ability as "poor" or "less good". Physically strenuous work components were present "quite to very often" in 23-79% and more in patients on sick leave ≥ 2 years. For those working, the interfering factors in the work environment concerned task and time demands. Supporting factors concerned meaning of work, interactions with co-workers and others. Self-rated work ability correlated moderately-highly positive with percentage of full-time employment, work-related risk factors and opportunities and constraints in the work environment. CONCLUSIONS: Poor self-rated work ability is common in patients with PM/DM indicating a need to identify interfering risk factors and support patients to enhance work performance.

The protocol and design of a randomised controlled study on training of attention within the first year after acquired brain injury.

BACKGROUND: To describe the design of the study aiming to examine intensive targeted cognitive rehabilitation of attention in the acute (<4 months) and subacute rehabilitation phases (4-12 months) after acquired brain injury and to evaluate the effects on function, activity and participation (return to work). METHODS/DESIGN: Within a prospective, randomised, controlled study 120 consecutive patients with stroke or traumatic brain injury were randomised to 20 hours of intensive attention training by Attention Process Training or by standard, activity based training. Progress was evaluated by Statistical Process Control and by pre and post measurement of functional and activity levels. Return to work was also evaluated in the post-acute phase. Primary endpoints were the changes in the attention measure, Paced Auditory Serial Addition Test and changes in work ability. Secondary endpoints included measurement of cognitive functions, activity and work return. There were 3, 6 and 12-month follow ups focussing on health economics. DISCUSSION: The study will provide information on rehabilitation of attention in the early phases after ABI; effects on function, activity and return to work. Further, the application of Statistical Process Control might enable closer investigation of the cognitive changes after acquired brain injury and demonstrate the usefulness of process measures in rehabilitation. The study was registered at ClinicalTrials.gov Protocol. TRIAL REGISTRATION: NCT02091453, registered: 19 March 2014.

Hand exercise intervention in patients with polymyositis and dermatomyositis: a pilot study.

OBJECTIVE: The aim of the present study was to develop a 12-week hand exercise intervention for patients with polymyositis (PM) and dermatomyositis (DM) and evaluate adherence, patients' opinions of the programme design and overall feasibility, and the effect on hand function and activity limitation after the intervention. METHOD: A pilot hand exercise intervention was conducted on a convenience sample of 15 patients with reduced handgrip strength and established, inactive PM and DM. Acceptable adherence was set at 75%. The programme was evaluated based on patients' opinions regarding exertion, the movements involved and overall feasibility. Hand- and pinch-grip strength, grip ability, dexterity and activity limitation were assessed. RESULTS: Eleven of 15 patients completed the intervention, with acceptable adherence of 78-100%. Measures of handgrip strength, dexterity and activity limitation were reduced at baseline compared with normative data from the literature. Throughout the intervention, rates of perceived exertion were scored between 'moderate' and 'fairly strong'. Finger abduction and adduction were excluded from the hand exercise programme because they were not feasible to perform. Repetitions of the exercise increased gradually to a maximum of 30 per movement. Patients regarded this as too time-consuming and suggested ten repetitions daily or 10-20 repetitions 2-4 times per week. There were some individual, clinically meaningful improvements in hand function and activity limitation. A comparison between baseline and after the intervention showed that the three-jaw (tripod) pinch-grip strength (left hand) had increased (p < 0.007; z = -2.7). CONCLUSION: A hand exercise programme was found to be feasible to perform by patients with established PM or DM. The effect was limited, with few individual improvements in hand function and activity limitation, indicating a need to increase the resistance in the movements and to limit the duration of each exercise session.

Using a profile of a modified Brief ICF Core Set for chronic widespread musculoskeletal pain with qualifiers for baseline assessment in interdisciplinary pain rehabilitation.

AIM: To describe the use of a "workable" visual profile of function and disability, based on a modified Brief International Classification of Functioning, Disability and Health (ICF) Core Set for chronic widespread pain, for initial assessments in a clinical setting of interdisciplinary pain rehabilitation teams. METHOD: The Brief ICF Core Set was slightly adapted to meet the needs of an interdisciplinary rehabilitation medicine team working in a university outpatient clinic and admitting patients referred from primary care. The Core Set categories were made measurable by means of eg, assessment instruments and clinical investigations. The resulting profile was given a workable shape to facilitate rapid understanding of the initial assessment outcome. RESULTS: Individual patients showed different profiles of problems and resources, which facilitated individual rehabilitation planning. At the level of the study group, the profiles for the Core Set component Body Functions showed that most patients had severe impairment in the sensation of pain and exercise tolerance categories of function, but most had resources in the motivation and memory categories of function. Likewise, for the component Activities, most patients had limitations in lifting and carrying objects and remunerative employment, but most had resources in intimate relationships and family relationships. At first, the use of the modified Brief ICF Core Set in the team conference was rather time consuming, but after a couple of months of experience, the team assessment took approximately 30 minutes to complete per patient. CONCLUSION: The profile of the modified Brief ICF Core Set for chronic widespread pain served as a common platform, facilitating cooperation between the rehabilitation team members and providing a uniform language, which helped in structuring the clinical work. The profile also provided an easily accessible, overall view of the patient's problems and resources, which helped in understanding the functioning situation of the patient.

Between unemployment and employment: experience of unemployed long-term pain sufferers.

OBJECTIVE: This study explored and analysed how patients experienced possibilities for, and barriers to, work return after participation in a multi-professional pain-rehabilitation program followed by a coached work-training program (CWT). PARTICIPANTS: Eleven informants (8 women/3 men) with long-term musculoskeletal pain who had participated in the CWT program for 4-21 months (mean=11) comprised the study. METHODS: A qualitative emergent design was used. Data collected with interviews were analysed using the constant comparison method of grounded theory. Triangulation in researchers were used. RESULTS: The analyses of the interviews resulted in the development of a three-category theoretical model, which was named "a way back to work". The main category "Experience of a way back to work" consisted of the informants' experience during the process between unemployment and employment. The category "Support" describes the help the informants received from various actors, and the category "Negative response" describes negative responses from the actors involved, which was an important barrier in the process between unemployment and employment. CONCLUSION: Professional individualised support, participants feeling involved in their rehabilitation process, coaching at real workplaces and multi-professional team including health care personnel, were valuable during the process towards work.

Alcohol habits in patients with long-term musculoskeletal pain: comparison with a matched control group from the general population.

This prospective study aimed to describe alcohol habits in patients with chronic pain compared with those in a matched control group from the general Swedish population. In total, 100 consecutive patients enrolled were matched against 100 individuals in a control group on the basis of age and sex. Alcohol habits were measured using the Alcohol Use Disorders Identification Test in both groups. The patients were recruited if they underwent a biopsychosocial pain analysis for possible participation in pain rehabilitation. The patients with chronic pain drank alcohol significantly less, less often, in smaller quantities, and became intoxicated less than the control group did. The study was rather small and at a single site, but its strengths were the comprehensive and simple design and the possibility to describe the sample's representativeness compared with other clinics on the basis of data from a national quality register.

The ICF and postsurgery occupational therapy after traumatic hand injury.

Recent studies have examined the effectiveness of hand rehabilitation programmes and have linked the outcomes to the concept of ICF but not to specific ICF category codes. The objective of this study was to gain experience using ICF concepts to describe occupational therapy interventions during postsurgery hand rehabilitation, and to describe improvement in functioning using ICF categories. In addition, investigated was the agreement between the ICF categories for occupational therapy interventions and the outcome measures used. Fifteen patients with traumatic hand injuries agreed to participate. Outcome measures were used to assess the following variables: range of motion, grip strength, pain intensity, upper-extremity functioning and health-related quality of life. Analysis of variance for repeated measures was used between the measures at baseline and at 3-month and 12-month follow-ups. The results showed that a pattern of occupational therapy interventions concerning body functions and body structures, activities and environmental factors could be identified during the early postsurgery phase and for interventions at participation level during the later phase. Agreement between occupational therapy interventions and outcome measures was found for 11 pairs. Three of the pairs concerned body function and eight were at the activity and participation level. During the rehabilitation process, the majority of improvements took place between baseline and the 3-month follow-up. We concluded that ICF categories can be used to describe occupational therapy interventions in postsurgery hand rehabilitation after trauma; that the use of ICF as a reference framework provides a clear picture of which health domains are addressed; and that a consistent use of ICF categories facilitates linking between rehabilitation interventions and outcome assessments, thereby increasing the possibility of showing the effects of these interventions.

Whiplash patients' experience of a multimodal rehabilitation programme and its usefulness one year later.

OBJECTIVE: The study aimed to explore and analyse how, 1 year after completing a rehabilitation programme, persons with long-term pain due to whiplash-associated disorders (WAD) experienced their participation, and what knowledge and strategies they had gained from it for handling their daily occupations. METHODS: The study had an emergent design. Thematised research interviews were conducted with nine informants. The results were analysed according to the constant-comparison grounded-theory method. RESULTS: Data analysis resulted in one core category, 'learning to manage WAD, a rehabilitation process', and three associated categories: 'chaos in life', 'a light in the tunnel' and 'managing long-term pain'. The core category and the categories describe the process the informants underwent from how they experienced life when starting rehabilitation to one year after completion. CONCLUSION: The informants described living with long-term whiplash-associated pain as 'chaos' before the rehabilitation programme. Participation helped them realise that there was a possible way for them to control their pain, regain their daily occupation and return to work. One year after rehabilitation the informants had started to accept their situation and regain occupations and life roles.