Margit Kooijman

General Introduction | 15 symptoms as acceptable notwithstanding the average improvement being above the threshold for clinically important change 28 . To help inform patients and clinicians on the likelihood of future outcomes, research into prognostic factors aims to detect factors associated with clinical outcomes to aid therapeutic management and identify targets for new interventions to improve the course of the health condition 29 . In 2004, a systematic review of prognostic studies on shoulder pain found that there was disappointingly little evidence for most factors that commonly were suggested to be of prognostic importance 30 . They found consistent evidence only for high pain intensity at baseline to be a strong predictor for a poor prognosis. As was to be expected, many studies were published on this topic since, especially in primary care settings. Hence, at the moment it is unclear if more studies are required or if there already is consensus on important prognostic factors. Organization of care Today, in the Netherlands, a high number of patients with shoulder pain visit a general practitioner or physiotherapist 31 . The annual consulting incidence in general practice for shoulder symptoms is estimated at 36 per 1000 person years 32 . General practitioners only refer more patients to the physiotherapist for back and neck pain 32 . In physiotherapy practice, about 10% of patients have shoulder complaints, which makes it the most common complaint after back and neck complaints 33 . The current Dutch guideline for general practitioners in the management of shoulder pain suggests a stepwise approach consisting of advice, watchful waiting, analgesia and referral for physiotherapy when these steps fail to reduce complaints sufficiently 34 . Referral to secondary care for non-traumatic shoulder pain is only indicated in case of atypical signs or when usual care leads to unsatisfactory results. There also is a short guideline available for physiotherapists 35 . It is based partly on scientific evidence and partly on best practice because the content of physiotherapy treatment is still under discussion. In both guidelines, attention is paid to diagnosis and treatment but there is only brief information on collaboration and whether or when to refer a patient or not 36 . This deficiency leads to the question what this presently looks like in practice? Sound patient care rests firmly on precise choice of providers and smooth transitions from one clinician to the other 18 . General practitioners and physiotherapists trained and equipped to perform musculoskeletal ultrasound in patients with musculoskeletal disorders is one example of the transition of musculoskeletal services from secondary to primary care in recent years. It appears like musculoskeletal ultrasound is being used increasingly with the intention to improve their diagnostics and assist them in selecting the most appropriate intervention 37,38 . Nevertheless, clear data on the uptake is unknown as are any considerations by practice owners and trained physiotherapists for providing and using musculoskeletal ultrasound.