Margit Kooijman

124 opens the door for freely exploring which and how context factors play a role in the management of patients with musculoskeletal diseases in general and perhaps with shoulder pain specifically. Recommendations for clinical practice and research First and foremost, additional studies need to confirm the results on existence of a therapist effect. By doing so in various settings (general practice, physiotherapy practice) and in various groups of patients also the necessary data are collected to gain insight in its effect size. When such an effect common to most or all physiotherapy / general practitioner encounters is reinforced, the next step is to investigate which factors might contribute substantially. Previous research identifying which factors explain therapist effect in primary care is mostly limited to age, experience and education and shows conflicting results and small effects 36 . Based on psychotherapy common factors and clinical experience in physiotherapy, a first initiative towards a common factors model in physiotherapy proposes an exploration of therapists’ pain perceptions and beliefs 28 . Considering our aim for opportunities to increase peoples’ functioning and vitality also with pain, this seems a wise next step. Of course, characteristics of the therapist do not stand-alone. Interaction with many other variables at different levels (patient, setting, patient-therapist interaction) seems obvious and will be a true challenge to unravel in the later future. Our findings do not yet offer specific recommendations to develop desired behaviour by clinicians. However, who better than physiotherapists and general practitioners themselves could deliver ideas and guide what best to investigate? Besides asking the question ‘how might I impact outcome?’ in private, discussions with colleagues or in professional intervision groups might yield valuable input for further scientific research based on - years of - clinical experience. Final reflections The final paragraph of this thesis on ‘management of patients with shoulder pain in primary care’ returns to the patient. A patient with pain and impairments, coping as best he can. Consulting a clinician, helping as best he can. Appreciation of the mutual good intensions, to me, seems the very starting point of every patient-clinician working alliance towards the desired outcome. Obviously, this outcome is ‘good health’. Right here though starts the teamwork, because what is good health is very individual. GPs and physiotherapists are highly trained medical professionals with ditto responsibilities. As seen in this thesis, in treating patients with shoulder pain they should