The evaluation, conducted at the Royal National Orthopaedic Hospital in Stanmore and published in Frontiers in Anesthesiology, was carried out in the shadow of a landmark legal ruling. Since the UK Supreme Court’s 2015 decision in Montgomery v Lanarkshire Health Board, informed consent in Britain has been judged by what a reasonable person in the patient’s position would want to know, not by what doctors customarily disclose. That standard, reinforced by the General Medical Council and the National Institute for Health and Care Excellence, treats consent as an ongoing dialogue rather than a signature on a form. Valid consent for an anaesthetic intervention therefore requires that patients not only hear about the procedure but genuinely perceive it as elective.

Peripheral nerve blocks pose a particular challenge to that ideal. Unlike general anaesthesia or a spinal injection, a nerve block is usually an adjunct — an additional technique layered onto the primary anaesthetic plan to deliver targeted postoperative pain relief. It carries its own technique-specific risks, from nerve injury to local anaesthetic toxicity, and its success depends on the operator’s skill and the patient’s anatomy. Professional bodies including PROSPECT and the American Society of Regional Anesthesia and Pain Medicine recommend regional analgesia for many orthopaedic operations, which can make the conversation feel more like a recommendation than an offer. The Stanmore team wanted to know whether patients, after all the disclosures were complete, actually registered a choice.

The study took the form of a prospective service evaluation between June and July 2024. Every adult scheduled for elective orthopaedic surgery who was offered a peripheral nerve block was eligible, and investigators independent of the patients’ clinical care administered a standardised 19-item bedside questionnaire on the first morning after surgery. Sixty-three of the 68 eligible patients took part, a response rate of 92.6 percent. The questions mapped onto recognised domains of shared decision-making — information provision, presentation of options, deliberation, and decision — and covered whether patients saw the block as optional, what they recalled receiving, what information they had engaged with before surgery, and how satisfied they were with the consent process.

The headline numbers were sobering. Although 59 of 63 patients remembered being offered a block, only 25 perceived it as completely optional. Twenty-six believed it was simply part of the anaesthetic, and 12 were unsure. Fifty-one patients — 81 percent — accepted the block, most citing the anticipated pain relief, and satisfaction was uniformly high: 82.5 percent were very satisfied and none reported any dissatisfaction. On the surface, then, a compliant pathway and happy patients. Beneath it, a consent process that had failed to transmit the one fact the law cares most about.

The most dramatic finding concerned memory. When asked an open-ended question — what anaesthetic do you recall having? — not a single one of the 63 patients who received a nerve block spontaneously mentioned it, even though most blocks were performed while the patient was awake before the general anaesthetic began. By contrast, 15 of the 16 patients who received neuraxial anaesthesia, such as a spinal injection, recalled it without prompting, an absolute difference of nearly 94 percentage points. The dissociation was sharpest within individual patients: of six people who received both a spinal technique and a nerve block in the same anaesthetic, all six spontaneously recalled the spinal, and none identified the block — including two who had received sedation, which argues against sedation as an explanation for the gap.

The team’s interpretation is that patients categorise the two techniques differently. A spinal injection presents itself as a discrete event, often involving visible preparation and a distinctly felt procedure, whereas a peripheral nerve block seems to be assimilated into the patient’s broader mental category of ‘the anaesthetic’. This echoes earlier research showing that fewer than half of patients can recall any block-related risk shortly after surgery, that knowledge scores are weakest in the regional anaesthesia domain on validated instruments, and that fewer than 40 percent of patients feel sufficiently informed to choose between regional and general techniques. Consent documentation, too, is frequently written above recommended reading levels, compounding the problem.

Two of the study’s comparisons carry practical weight. Receipt of a written information leaflet made no measurable difference to whether patients recognised the block as optional — 41.7 percent of leaflet recipients versus 39.2 percent of those without, a null result with a p-value of 1.00. But prior personal experience of regional anaesthesia nearly quintupled the odds of recognising optionality: 62.5 percent of patients who had experienced a regional technique before perceived the block as elective, against 26.3 percent of those without such experience (odds ratio 4.67, p = 0.009). In other words, lived experience taught patients what leaflets could not. Passive disclosure, the authors suggest, is not enough; understanding appears to come from something closer to dialogue and demonstration.

The findings are a caution against the reflex to treat patient satisfaction as proof of valid consent. Satisfaction, prior work shows, reflects trust and rapport with clinicians far more than the cognitive content of the consent conversation. The authors are careful about what their data do and do not show: the three-category measure of optionality is a simplification, a strongly recommended intervention can be part of good shared decision-making, and some patients legitimately prefer to delegate decisions to a trusted expert. But they argue that even delegation presupposes awareness that a choice exists, and that under Montgomery even a strongly recommended treatment must be understood to be declinable. A pathway in which fewer than half of patients recognise the elective nature of an intervention, they conclude, is unlikely to be delivering the dialogue that guidance requires.

The response at Stanmore has been concrete. The perioperative consent pathway now includes a standardised opening phrase that explicitly frames the nerve block as one of several options the patient may accept or decline, and a mandatory teach-back step in which patients describe, in their own words, the option they have chosen and an alternative. The changes align with the Association of Anaesthetists’ newly issued 2026 consent guidelines, which require anaesthetists to actively confirm that information has been understood rather than rely on disclosure alone. Re-measurement is planned. The authors acknowledge the limits of a single-centre, descriptive evaluation — no pre-specified primary outcome, an unvalidated instrument, potential recall and social-desirability biases, and the exclusion of non-English speakers, arguably the group most at risk of comprehension gaps. Yet they argue the underlying failure mode, patients failing to categorise a nerve block as a distinct elective intervention, is unlikely to be confined to one specialist hospital, and they invite replication elsewhere. With the UK’s forthcoming Eighth National Audit Project expected to deliver fresh data on serious regional anaesthesia complications and reshape how risks are communicated, the timing of this quiet audit of the consent conversation could hardly be better.

Subject of Research: Patient perception of optionality in informed consent for peripheral nerve blocks in elective orthopaedic surgery

Article Title: Do patients perceive peripheral nerve blocks as optional interventions for elective surgery? An evaluation of informed consent at a UK specialist orthopaedic centre

Article References: Snooks, R., Ismail, S., Vora, R., Starsmore, L., Herath, B., Sell, A., & Bellew, B. (2026). Do patients perceive peripheral nerve blocks as optional interventions for elective surgery? An evaluation of informed consent at a UK specialist orthopaedic centre. Frontiers in Anesthesiology, 5, Article 1956429. https://doi.org/10.3389/fanes.2026.1956429

Image Credits: AI Generated

DOI: 10.3389/fanes.2026.1956429

Keywords: informed consent, peripheral nerve block, regional anaesthesia, shared decision-making, patient autonomy, Montgomery v Lanarkshire, orthopaedic surgery, perioperative medicine, teach-back, risk communication, patient satisfaction, service evaluation

The study, published as an open-access review in the journal Supportive Care in Cancer, evaluated the NUH Prehabilitation Service, a multimodal programme combining exercise, nutritional support and psychological preparation. Rather than offering the same package to everyone, the service follows a tiered, risk-stratified model endorsed by Macmillan Cancer Support, in which patients are allocated to one of three pathways according to clinical need. High-risk patients, identified using factors such as frailty, functional capacity, comorbidity and treatment complexity, were assigned to the Specialised pathway, attending supervised one-to-one or two-to-one exercise sessions with the hospital’s prehabilitation team up to three times a week. Lower-risk patients joined the Targeted pathway, attending community-based group classes led by an external provider that combined modified high-intensity interval training with strength exercises. A third group, the Universal pathway, received an individualised home exercise prescription with weekly check-ins for education and advice — an arms-length offer designed for patients who were already independently active or lived outside the immediate area.

The scale of the programme is striking. Of 1,961 patients referred over the 38-month period, 1,720 were included in the analysis, spanning seven surgical specialities including colorectal, gynaecological oncology, hepatopancreatobiliary, upper gastrointestinal, urology, head and neck, and thoracic surgery. That equates to an average of around 52 eligible referrals per month, a level of uptake the authors interpret as strong engagement from referring clinical teams. The cohort had a median age of 67 years, slightly more women than men, and nearly half were classified as obese. Colorectal surgery accounted for the largest share of participants at 38.5 per cent, followed by gynaecological oncology at 20.3 per cent.

To measure whether the programme worked, the team relied on validated functional and psychological instruments collected as part of routine clinical monitoring. Aerobic capacity was assessed with the Incremental Shuttle Walk Test, an externally paced protocol in which walking speed increases with each audio-cued level until the participant can no longer keep up. Lower-limb strength and endurance were measured with the 60-second sit-to-stand test, and grip strength was recorded with a hand-held dynamometer. Psychological well-being was tracked using two widely used self-report questionnaires: the Patient Health Questionnaire-9 for depression and the Generalised Anxiety Disorder-7 scale for anxiety. Self-reported weekly physical activity and the number of completed strength sessions rounded out the behavioural picture.

The results showed statistically significant improvements across every domain measured. On average, patients walked 57 metres further on the shuttle walk test after the programme, a gain with a moderate effect size that exceeds the minimal important differences of 35 to 53 metres typically reported for rehabilitation in long-term conditions. Sit-to-stand performance improved by six repetitions, roughly double or triple the threshold generally considered clinically meaningful. Depression scores fell by about two points, meeting the minimal clinically important difference established in UK primary care cohorts, while anxiety scores also decreased significantly. Perhaps most dramatically, self-reported weekly physical activity rose by 142 minutes — more than doubling — and the number of weekly strength sessions increased by 2.4, both with large effect sizes.

Importantly, these gains were not confined to the most intensive pathway. Although patients in the Specialised group showed greater improvements in depression scores compared with the Targeted group, and the Universal group increased strength sessions more than the Targeted group, most outcomes — including aerobic capacity, anxiety, grip strength and overall physical activity — showed no statistically significant differences between pathways. For the shuttle walk test, gains exceeded the minimal important difference in all three groups: 43 metres in Universal, 56 metres in Targeted and 64 metres in Specialised. The authors suggest this indicates that a tiered model can deliver meaningful benefit across all starting levels, and that even a low-intensity, arms-length offer may be a viable and scalable option for lower-risk patients when service capacity is constrained.

The findings align closely with other NHS prehabilitation programmes. The Greater Manchester Prehab4Cancer programme, one of the best-known community-based models, previously reported shuttle walk gains of around 50 metres and sit-to-stand improvements of 4.8 repetitions — figures comparable to those seen in Nottingham. The consistency across services strengthens the case that prehabilitation can be delivered at scale within publicly funded healthcare systems, not only in tightly controlled research trials. The Nottingham evaluation is also notable for reflecting routine clinical care rather than a research-driven intervention, which the authors argue enhances its real-world relevance and supports generalisation across a broad cancer population.

Not everything translated into clinically meaningful change. Although anxiety scores fell statistically significantly, from an average of about 6 to 4, the change fell short of the established minimal clinically important difference of four points on the GAD-7 scale, and baseline anxiety in this cohort was already low. The authors also note that research in oncology populations suggests the conventional GAD-7 threshold of 10 may underestimate anxiety in cancer patients, with better sensitivity at cut-offs of around 7 to 8, which calls for cautious interpretation of absolute scores. Depression, by contrast, showed a change that met the clinical significance threshold, and the greater improvement seen in the Specialised pathway hints that structured, individualised psychological support may add value over more generic delivery.

The evaluation is candid about its limitations. The analysis used a complete-case approach, excluding 241 patients with missing data, and assumes that data were missing completely at random — an assumption that, if wrong, could bias effect estimates. The observational design lacks randomisation, so causal inference is limited, and between-group comparisons were unadjusted for baseline differences and are therefore exploratory. Physical activity was self-reported, leaving results vulnerable to recall and social desirability bias. Selection bias may also operate upstream: referral depended on clinician discretion, tumour type and service capacity, and patients allocated to lower-intensity pathways may have been healthier or more motivated to begin with. Notably, the evaluation did not capture postoperative outcomes such as length of stay or complication rates, so it remains unknown whether the preoperative gains translated into downstream surgical benefits — a gap the authors flag as a priority for future data collection.

Engagement data reveal the practical friction points that any national rollout would need to address. A total of 8,250 service sessions were delivered, averaging 4.9 per patient, with median time in the service of 33.4 days — long enough, the authors note, to sit above the three-week threshold associated with improvements in postoperative complications, though benefits can begin to emerge within two weeks. Documented reasons for non-completion included short windows before surgery, non-attendance and discharge after assessment, often reflecting patient preference or a perception of already being fit enough. Reported barriers included travel distance, competing hospital appointments and caring responsibilities. Among 662 patients who completed a three-month postoperative questionnaire, 83.3 per cent agreed that prehabilitation helped them prepare for surgery and 61.1 per cent felt it supported their recovery — although only 31.2 per cent reported being more physically active afterwards, while 38.1 per cent felt less active, underscoring how difficult it is to sustain behaviour change through the surgical period itself.

The authors recommend several service improvements: routinely recording hospital length of stay to strengthen benchmarking and the health-economic case, and mitigating engagement barriers through hybrid delivery, digital follow-up and clearer clinician-led communication about the benefits of prehabilitation. They conclude that a multimodal, tiered prehabilitation service aligned with national guidance was linked to improvements in mood, strength and functional capacity, supporting patients’ surgical preparation and recovery, and that the findings justify integrating prehabilitation into routine cancer care. With 45 million cancer surgical procedures expected annually worldwide by 2030, and systematic reviews suggesting multimodal programmes may shorten hospital stays by around two days while proving cost-effective in a majority of economic evaluations, the Nottingham experience offers a template for how health systems might prepare a growing surgical population — not in the operating theatre, but in the crucial weeks before it.

Subject of Research: Multimodal prehabilitation before cancer surgery delivered through tiered NHS pathways

Article Title: Delivering prehabilitation in cancer surgery: a service evaluation at Nottingham University Hospitals

Article References: Alharbi, A., Haywood, A., & O’Connor, D. (2026). Delivering prehabilitation in cancer surgery: a service evaluation at Nottingham University Hospitals. Supportive Care in Cancer, 34(10), Article 973. https://doi.org/10.1007/s00520-026-11113-y

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11113-y

Keywords: prehabilitation, cancer surgery, NHS, exercise, risk stratification, functional capacity, depression, anxiety, physical activity, service evaluation, Nottingham University Hospitals, Supportive Care in Cancer

The study, conducted at Chrysalis Associates, a specialist developmental trauma and attachment service in the north of England, evaluated a 30-hour neuro-collaborative Theraplay-informed intervention delivered between April 2020 and April 2024. The therapeutic package comprised three equal components: ten hours of Theraplay-informed family therapy involving parents and children, ten hours of therapeutic parenting sessions guided by the principles of dyadic developmental parenting, and ten hours of sensory regulation work delivered directly to children or psycho-educationally to parents. This integrative design deliberately expands on Perry’s neurosequential model, which proposes treating trauma by targeting the brainstem first, then the limbic system, and finally the cortex. Instead of moving sequentially, the neuro-collaborative approach addresses multiple brain systems concurrently, pairing body-based regulation with attachment-focused play and reflective parenting support.

The researchers compared 35 autistic care-experienced children with 172 non-autistic children who received the same intervention. The autistic group had an average age of just over nine years, ranged from four to seventeen, and attended on average more than 96 percent of their scheduled sessions. Outcomes were measured before and after therapy using four well-validated caregiver-report instruments: the Trauma Symptom Checklist for Young Children, the Child Behaviour Checklist, the Behaviour Rating Inventory of Executive Function, and the Assessment Checklist for Children. Paired t-tests and analyses of covariance controlling for age and gender were used to assess change within and between the groups.

The results told a nuanced story. Across the full cohort, every outcome measure improved significantly, and after applying a Bonferroni correction for multiple comparisons, total post-traumatic stress, post-traumatic stress arousal, total behavioural problems, and oppositional defiant problems remained significantly reduced, with effect sizes ranging from small to approaching medium. The larger non-autistic group alone also showed statistically significant improvements on most measures. The smaller autistic group did not reach statistical significance, but scores moved consistently in the direction of improvement with encouraging effect sizes, including a moderate effect for reduced rule-breaking behaviour. Crucially, the analyses of covariance found no significant difference in treatment response between autistic and non-autistic children once pre-treatment scores, age, and gender were accounted for.

The theoretical rationale for the intervention rests on how early relationships shape developing regulatory systems. Drawing on Schore’s account of right-hemisphere development and Porges’ polyvagal theory, the authors argue that attachment experiences sculpt the autonomic and nonverbal systems underlying emotional attunement, bodily awareness, and social engagement. Theraplay, a structured, playful, and largely preverbal approach organised around the domains of structure, engagement, nurture, and challenge, is designed to intervene precisely at this nonverbal, embodied level. Because autistic children often process sensory input and social cues differently, the therapy was adapted flexibly, honouring the child’s developmental stage and sensory profile rather than demanding eye contact or touch that could prove dysregulating.

The authors also invoke monotropism theory, which describes the intensely focused attentional tunnel characteristic of autism, to explain how trauma and autistic hypersensitivity can interact. A child whose nervous system is hypervigilant for danger after trauma, and whose attention is already narrowly channelled by autistic monotropism, may become overwhelmed by stimuli inside that channel while missing cues outside it. The intervention’s sensory regulation component, drawing on the Just Right State program and the Alert Program, helps parents create predictability and reduce overload, while Theraplay-informed sessions teach carers to synchronise with the child’s attention rather than fight against it, building experiences of being seen, understood, and co-regulated.

Not every measure responded identically across groups. On the Assessment Checklist for Children, which probes attachment-related relational behaviours, the non-autistic group improved significantly while the autistic group’s scores on indiscriminate and non-reciprocal scales remained stable or rose slightly. The researchers argue this divergence is expected and even reassuring: non-reciprocal and indiscriminate friendliness in trauma-exposed children typically reflects damaged internal working models, which attachment-rich therapy can repair, whereas analogous presentations in autistic children stem from innate neurobiological differences in social reciprocity. Attempting to modify those differences therapeutically would be neither appropriate nor neurodiversity-affirming, and the authors caution that the checklist itself may simply be insufficiently sensitive to capture relational change in autistic children.

The study’s significance lies partly in dismantling a persistent clinical misconception. Some practitioners have assumed that Theraplay’s emphasis on touch and eye contact makes it unsuitable, or even harmful, for autistic children. This evaluation found no evidence of deterioration in functioning and instead suggests the model can be adapted in a neurodiversity-affirming way to achieve trauma-related outcomes comparable to those of non-autistic peers. Prior scoping reviews had already found that interventions relying less on verbal skills and emphasising caregiver involvement, both hallmarks of Theraplay, suit neurodivergent children who have experienced interpersonal trauma. The present study extends that literature to the specific and understudied intersection of autism, developmental trauma, and attachment disruption in care-experienced children.

Nevertheless, the authors are candid about the limitations inherent in practice-based evidence. The evaluation was retrospective rather than randomised, the autistic subgroup was small, the integrative design makes it impossible to isolate which component drove change, and all outcome data relied on caregiver report vulnerable to expectancy effects. Formal treatment fidelity checks were not routinely conducted, dropout information was not collected, and the generic psychometric measures were not adapted to autistic symptomatology. Changes in executive function and attachment-related outcomes, while directionally positive and at times showing moderate effect sizes, did not reach significance, likely reflecting insufficient statistical power.

The research team concludes that the 30-hour neuro-collaborative Theraplay-informed intervention is effective for children with developmental trauma and attachment disruption, and may also benefit autistic children, though larger, adequately powered trials are needed to confirm this. They call for qualitative research capturing the lived experiences of autistic children, their carers, and their therapists, alongside the development of autism-sensitive assessment tools. For now, the message for services supporting care-experienced autistic children is cautiously optimistic: attachment-based, sensory-informed, neurodiversity-affirming therapy deserves a place in the treatment conversation, and services are encouraged to evaluate and publish their own anonymised data to build the collective evidence base.

Subject of Research: Evaluation of a neurocollaborative Theraplay-informed psychotherapeutic intervention for developmental trauma and attachment difficulties in autistic looked after children

Article Title: The Impact of a Neurocollaborative Theraplay®-Informed Intervention on the Presentations of Developmental Trauma and Attachment Difficulties in a Sub-Group of Autistic Looked after Children: a Retrospective Service Evaluation

Article References: Purrington, J., Hartley, G., Price, A., Bass, E., Godfrey, C., Lynch, J., & Mukherjee, R. (2026). The Impact of a Neurocollaborative Theraplay®-Informed Intervention on the Presentations of Developmental Trauma and Attachment Difficulties in a Sub-Group of Autistic Looked after Children: a Retrospective Service Evaluation. Journal of Child & Adolescent Trauma. https://doi.org/10.1007/s40653-026-00964-6

Image Credits: AI Generated

DOI: 10.1007/s40653-026-00964-6

Keywords: autism, developmental trauma, attachment disruption, Theraplay, looked after children, sensory regulation, therapeutic parenting, neurodiversity, psychotherapy outcomes, service evaluation, child and adolescent trauma, care system