1. This Outcome report is based on data from patients who completed a Pain Management Programme at the RealHealth Treatment Centre in Coventry between November 2013 and November 2014. Pain related disability was reduced on average by 15% from start to completion of the Pain Management Programme, and these improvements were maintained at a six-week follow up. Average levels of emotional distress were reduced by 32% on programme completion. Programme users showed an average reduction in fear of movement and activity avoidance of 14%,after programme completion compared to baseline levels. Confidence in performing activities despite pain increased by 40% from start to completion of the programme. Patients showed an average reduction in catastrophic thinking of 17% at programme completion compared to initial pre-programme assessments. On average, functional ability improved by 16% from programme start to programme completion, and average improvements of 21% were observed 6 weeks following programme completion, indicating further gains. Over 90% of patients verbally reported meaningful positive changes in aspects of their functioning and quality of life Representative sample based on 34 patients

2. The Roland & Morris Disability Questionnaire (RMDQ) is a widely used health status measure for low back pain, providing self-ratings of the level of physical disability experienced by the patient as a consequence of the pain. Scores on the RMDQ range from 0-24, with higher scores indicating a greater level of pain related disability. Our data shows that for the clients in the Pain Management Programme there was a noticeable trend in average reduction of pain related disability scores between admission and discharge from the programme. The Pain Self-Efficacy Questionnaire (PSEQ) is a 10-item questionnaire developed for people with ongoing pain to assess a patient’s confidence in performing activities while in pain. Higher PSEQ scores indicate stronger self- efficacy beliefs and are associated with return to work and maintenance of functional gains. Scores on the PSEQ were increased by 40% from start to completion of the programme, indicating significant improvements in self- efficacy beliefs. These benefits were generally maintained at a 6 week follow up, with some expected reduction but not to pre-PMP levels. Reducing Pain-Related Disability Improving Self-Efficacy Real Health 2014

3. The TAMPA Scale for Kinesiophobia (TSK) is an 11 item questionnaire that provides subjective self-report ratings of the extent of fear of movement or activity as a result of chronic pain. Possible scores on The TSK range from 0 -44, with higher scores indicating an increasing fear of movement, injury or re-injury. Scores above 26 are usually of clinical concern. Programme users showed a promising reduction in TSK scores of 14% from programme start to programme completion, with a mean reduction maintained by 6 weeks following programme completion. Reducing fear of movement Reflecting on positive changes Over 90% of patients verbally reported meaningful positive changes in aspects of their functioning and quality of life. Patients were proactively pacing themselves better. Confidence in undertaking exercise improved. There was less avoidance of daily tasks. Programme users had made a real effort to routinely improve posture. Patients were more willing to reduce their pain medication. Analyses of our qualitative information based on patients’ feedback indicate meaningful positive changes through attending the programme. The highlights from the qualitative data are as follows: Real Health 2014

4. Scores on the Catastrophising subscale of the PRSS range from 0 to 5, with higher scores indicating more frequent catastrophising when experiencing pain. Our data show a modest reduction in PRSS catastrophising scores from the start of the programme to completion. Reductions were maintained at follow up compared to before the programme. This indicates that the programme started to meaningfully decrease the extent of clients’ catastrophic thinking. Reducing catastrophic thinking Enhancing coping beliefs Meaningful cognitive change is central to clients’ progress. The Pain-Related Self- Statements Scale (PRSS) is an 18 item cognitive measure of the extent of catastrophic thinking and coping beliefs. Nine items relate to catastrophising and nine items relate to coping beliefs. Facilitating Cognitive Change Scores on the Coping subscale of the PRSS range from 0 to 5, with higher scores indicating more frequent coping beliefs when experiencing pain. Our data show an increase in PRSS coping scores of 15% from the start of the programme to completion. Increased coping beliefs were maintained at follow up compared to before the programme. This indicates that the programme meaningfully improved the extent of clients’ coping beliefs and improvements were maintained over the 6 weeks following programme completion. Real Health 2014

5. Reducing emotional problems The CORE Outcome Measure is a 34-item questionnaire, comprising emotional health dimensions, designed to measure the ‘core’ of a person’s distress, including anxiety and depression, subjective well-being, commonly experienced problems or symptoms and life/social functioning. It also includes items on risk to self and to others. Each item is scored on a 5-point scale ranging from 0 (not at all) to 4 (most or all the time). The total score is calculated by adding the response values of all 34 items, giving a range of 0 to 136. Higher scores indicate greater emotional distress. Total scores on the CORE Outcome Measure indicate that average levels of emotional distress were reduced meaningfully at the end of the programme by 32%. Whilst emotional distress levels rose at follow-up they remained well below the level observed at the start. Reclaiming lost roles Analyses of our qualitative information based on patients’ feedback indicates meaningful improvements to aspects of life functioning. The highlights from the qualitative data are as follows: Patients reported some improvement in their general well-being. Patients started making some positive changes in their interactions with other people. Patients were able to progress goals relating to hobbies. Where relevant, patients were ready to positively address and make real sustainable changes regarding their work capacity. Real Health 2014

6. Improving functional ability Functional ability measures were taken to assess any improvements in strength, flexibility, co-ordination and self-confidence in activity over the course of the programme. Specific functional ability measures included timed walk, sit to stand, and climbing stairs. These measures were taken at the start of the programme, on completion of the three-week programme, and at a follow up at 6 weeks after programme completion. Walking further Walking distance improved by 10% at the end of the programme with further gains observed at follow-up, indicating a 19% improvement compared to the start of the programme. Real Health 2014

7. Climbing stairs There was a 25% average improvement in sit-to-stand ability by the end of the programme and these gains were maintained at follow-up. Moving better A 12% average improvement was noted at the end of the programme which had risen to 20% average improvement by follow-up, indicating patients were continuing to build on their gains. Real Health 2014

8. “I am feeling much more positive about the future. I’m really happy to be more mobile and able to exercise. Thank you” What our patients have said: “Different people will gain different things, but I think everybody will take away something positive from the programme that helps them manage their particular pain” “The PMP has made me understand how to handle my pain better, cope with flare ups and how to live as normal a life as possible” “This has been a very powerful and educational course for me and has helped me enormously in sorting out priorities and understanding how I can be more in control” “I am more flexible and understand pain better and how I can deal with it” “Overall, the course was excellent and each session executed really well” “I got confidence that I can live a more normal life in spite of pain. RealHealth gave me confidence and brought me back to bearable level. I can now achieve more from life” “Best place to help to turn your life around, special staff that want to help you and understand where you’re coming from and look after you so well” “More positive about coping with pain, moving much more, feel confident about exercise” “It has made me realise that pain should not run my life. Also the stepping stones to a new me and a different life style” “Overall the programme was very informative and all the staff very professional and helpful always giving time and individual advice when needed, especially pinpointing particular problems with posture etc.” Real Health 2014