Margit Kooijman

General discussion | 117 It is increasingly recognised that the multidimensionality characterizing pain in musculoskeletal complaints such as shoulder pain, requires an integrative and personalized approach for its treatment 1 . According to the new movement of ‘positive health’, this means a shift in focus from illness to health; from fixing the disease to opportunities to increase peoples’ functioning and vitality, also with pain 2 . It recognizes six dimensions of equal importance: mental wellbeing, meaningfulness, quality of life, participation, daily functioning and bodily functions 3 . For this reason, clinicians face the challenge that management is about functions, activity, movement, rehabilitation and attitudes rather than the traditional model of diagnosis and medical treatment 4 . This challenge certainly applies to the management of patients with shoulder pain in primary care, where diagnostic uncertainty exists in combination with the lack of robust evidence for effective treatment. To explore some leads for improvement, in this thesis, we opted for a pause to reflect on the current management of patients with shoulder pain by physiotherapists and general practitioners. In this final chapter, we will discuss the results presented earlier and make suggestions where we could go from here. I Patients with shoulder pain in primary care Shoulder complaints often arise gradually (chapter 2) and are frequently considered relatively harmless and ‘part-of-the-job’ 5 . As a consequence, many patients with shoulder pain already have chronic complaints when they present themselves at the clinician (chapter 2) . And because of the relatively low number of patients with shoulder pain who access the physiotherapist through direct access (chapter 2) , the potential influence of the general practitioner on management is considerable. In accordance with national and international guidelines and opposed to the situation in many other countries, Dutch general practitioners do not very often refer patients to secondary care (chapter 2 & 3) , which is to be appraised. However, management by GPs and physiotherapists in primary care itself draws attention due to a rather substantial rate of applied interventions in patients with non-traumatic shoulder complaints (chapter 3) . The tendency toward action rather than inaction by clinicians, referred to as commission bias, is an area for improvement in the process and content management of shoulder pain. Process of care In two thirds of the patients with shoulder pain referred by the general practitioner for physiotherapy, the referral was given during the first consultation (chapter 2) , which is not in line with the wait-and-see policy advocated by the current clinical guideline for general practitioners 6 . It should be noted however, that early proactive treatment is known to lead to decrease pain intensity, improve activity levels and reduction of