Margit Kooijman

Summary | 131 Shoulder pain is one of the most common presentations of musculoskeletal pain. A definition of shoulder pain is not so easy though. Uniformity in diagnostic labelling is complex because of the weak correlation between structural factors and clinical presentation. Also, meta-analyses on the diagnostic value of physical examination tests contend that no single test is pathognomonic for any specific diagnosis. Next to difficulties in making a diagnosis, in recent years, a vast number of meta-analyses have revealed that no robust evidence is available that any intervention leads to statistically significant or clinically relevant benefits over one another or placebo. When more research on diagnosis and interventions does not seem to add to better outcome, we need to decide wisely on the way forward. Therefore, in this thesis, we opt for a pause for reflection on the current management of shoulder pain in primary care. In chapter 1 , the rationale to do so is described in more detail. The aim of this thesis is to explore some leads to improve care for patients with shoulder pain by physiotherapists and general practitioners. It addresses the question ‘where are we now?’, which we pose in three domains: process and content of care, diagnosis and prognosis and contextual factors. I Process and content of care Chapter 2 describes the characteristics and current care of patients with shoulder syndromes in primary care general practice and physiotherapy practice. In addition, this study investigated whether there are differences between patients treated by the general practitioner, patients who were referred by the general practitioner for physiotherapy and patients who came to the physiotherapist via direct access. The main conclusions were that there is a considerable group of patients with persistent complaints, that in the majority of patients the complaints developed gradually and that many patients waited a long time before visiting a healthcare provider. It also emerged that patients who were referred for physiotherapy were prescribed less medication but more often consulted a general practitioner than patients who were only treated by the general practitioner. Contrary to the recommendations in the guideline, the referral for physiotherapy was often given in the first consultation. In chapter 3 , the treatment of four common types of shoulder complaints by general practitioners and physiotherapists was compared in order to gain more specific insight in what goes well and where there are possibilities for improvement. This vignette study showed that the extent to which general practitioners and physiotherapists agree