Balancing analgesia and function with patient preference and expectation

Carvalho et al. present a valuable discussion on the analgesia–function trade-off and provide a pragmatic contextual framework to guide the choice between motor-sparing and denser, motor-affecting regional techniques [1]. Their emphasis on avoiding protocol-driven practice and instead tailoring anaesthetic strategy to patient and procedural context is commendable. We agree that preserved muscle strength alone does not guarantee meaningful mobilisation or early discharge if pain remains poorly controlled. Postoperative pain that is managed inadequately may cause many issues especially in older and frail patient populations [2]. A key strength of the editorial is its recognition that not all patients derive equivalent benefit from distal, motor-sparing techniques. Evidence that regional anaesthesia can contribute to delirium reduction further underscores the need to prioritise analgesic adequacy where appropriate [3]. The discussion could go further by highlighting the central role of patient engagement and shared decision-making in maximising the intended benefits of regional anaesthetic techniques. Patients want to be involved in decision-making related to anaesthesia care and this has been shown to improve patient satisfaction [4]. While the authors' reference patient-centred care, they do not address how patient preferences, expectations and level of understanding may influence outcomes and patient satisfaction. A motor-sparing block provides potential for early mobilisation but whether that potential is realised depends on whether the patient understands, values and participates actively in postoperative rehabilitation together with a realistic expectation of postoperative comfort. Pre-operative consultation offers a powerful opportunity to assess and engage patients. Failure to set expectations adequately or educate patients has been shown to result in pre-operative anxiety, inadequate preparation for discharge and suboptimal pain control strategies [5]. Explaining the trade-offs between strength preservation and analgesic density, and the potential of suboptimal analgesia or motor impairment, is essential. But equally important is enabling patients to appreciate what is required of them: early engagement with physiotherapy; participation in mobilisation despite some discomfort; and recognition that avoiding complications such as gastrointestinal adverse effects or delirium depends partly on their own mobilisation efforts. Without clear expectation setting, the benefits of a motor-sparing technique may be lost. A patient who opts for a motor-sparing approach but declines or is unprepared for early mobilisation gains little from preserved muscle function. Conversely, a patient willing to prioritise comfort may knowingly choose a denser block to optimise pain control but with a slower recovery of motor function. In both instances, shared decision-making ensures that the chosen block aligns not only with clinical context but with the patient's capacity and willingness to engage in their recovery plan. Carvalho et al. are right to advocate for flexibility and clinical judgement. We argue this flexibility should incorporate not only clinician assessment of context but also patient expectations and readiness to practise the behaviours that motor-sparing techniques are designed to support. By combining clinically grounded frameworks with genuine shared decision-making and patient engagement, the peri-operative team can ensure that the potential benefits of regional anaesthesia – motor preservation; comfort; early mobilisation; reduced duration of hospital stay; and avoidance of hospital acquired complications – are achieved.