Margit Kooijman

16 As another opportunity to choose the best available health care provider, patient self-referral to physiotherapy was introduced in the Netherlands in 2006. Before that date, a referral from the general practitioner was necessary. The proportion of self- referrers has been rising since, up to more than 56% in 201839. However, it is still unclear whether patients are able to choose the qualitatively best available care provider 40 . Well-timed referrals by patients themselves and clinicians are essential as treatment is most beneficial when provided at the right place and at the right time 18 . To assess if or to what extent support herein is desirable, information on the current care processes for different modes of access is required but lacking at the same time. Interventions In recent years, a vast number of meta-analyses have been published on the effectiveness of conservative interventions for patients with shoulder pain 41-49 . They generally reveal that although some interventions have more effect than no treatment on the short term, in the long term no robust, high quality evidence is available that any intervention or combinations of interventions leads to statistically significant or clinically relevant benefits over one another, placebo or other treatments such as medication or surgery. Consequently, before investing in more research on interventions in itself, information is required on current use and whether management decisions on interventions by the main clinicians actually match each other. Context factors Besides the intervention(s) applied, lately more research explores the role of so-called contextual factors 50,51 . These are general or non-specific factors influencing - the effectiveness of - treatment such as those related to the patient, practitioner or setting 52 . Although acknowledged within the field of psychotherapy, in primary care settings contextual factors are much less known and investigated. A study on management decisions in non-traumatic complaints of arm, neck and shoulder in general practice, found that absence of convincing evidence in favour of the treatment options investigated, may leave more room for personal preferences of both general practitioner and patient 53 . Knowing this, the question arises how these contextual factors influence the effectiveness of treatment in patients with shoulder pain?