Margit Kooijman

General discussion | 119 think about health, show that patients need to know about the variability and development of symptoms as it affects their self-care and care-seeking behaviour 13 . Self- management is an outcome of any successful treatment as it empowers a person to cope with the dynamic process of wellness and illness. Combined with the professional perspective, such empowerment opens up the possibility to co-create effective, personalized management of shoulder pain. Recommendations for clinical practice and research First of all, awareness of clinicians is required on the pitfall of being inclined to act, whether this concerns referrals to others or interventions like pain medication or therapy. Listening and giving advice is not only just as good an intervention; it is an indispensible part of treatment. By educating patients, clinicians also facilitate preventive treatment strategies for those presenting with mild symptoms and -as yet- few limitations in function and participation. This is especially important in absence of clear underlying aetiological mechanisms. As a step beyond bringing together members from different disciplines, an integrated education of professions could be a fruitful path to deepen understanding of and build trust in each other’s knowledge and abilities, thereby strengthening collaboration in primary care 7,8,14,15 . Because current thesis does not focus on the effects of earlier versus later referral and the capability of primary care clinicians to do so, this multifaceted and very important issue remains for further investigation. More specifically, concerning the timing of referrals, it is important to address the question why a discrepancy between recommended and actual care exists, and not put aside the accumulated clinical experience of general practitioners. Future research should also incorporate both the perspective of patients and clinicians in an attempt to identify more precisely whether it is the patient who needs more education on his or her complaints or the clinician on the importance of educating the patient. II Diagnosis and prognosis Previous research extensively points out the relatively poor outcome for patients with shoulder pain 16,17,18 . Our study added on that by showing that 37% of patients referred for physiotherapy returned to their GP afterwards (chapter 2) . This close observation of pain-related healthcare utilization beyond the treatment episode is less common but may indicate suboptimal treatment response, the presence of more complex needs or unwarranted escalation of care 19 . As the socio-economic impact as a result of