Margit Kooijman

32 prescribed less medication. The guideline for shoulder complaints from the Dutch College of General Practitioners recommend a stepwise approach in which the patient is referred for physiotherapy when there is no improvement with rest and advice (‘wait and see’) and pain medication for one or two weeks (preferably paracetamol) 9 . When pain is the main problem, extended treatment with analgesia is indicated. Physiotherapy is mainly indicated in the presence of a limited range of motion or other functional limitations. Although the duration of the complaints does not appear on GP records, the high number of first visit referrals indicates a discrepancy between the guide- lines and practice regarding the time frame for referral to physiotherapy. Further experimental research into the long-term effectiveness of early versus later referral is required to determine the preferred procedure. Duration of the complaints, level of pain, presence of functional limitations and concomitant cervical or cervicothoracic dysfunction will need to be taken into account. In previous research, it was demonstrated that patients with shoulder complaints make as much use of direct access as the general patient population when attending the physiotherapist 17 . However, the results of this study show that patients with shoulder syndromes make less use of direct access; only 13% came through direct access compared with 22-44% of the entire patient population attending the physiotherapist from 2006 to 2010. It is known that self-referral decreases with age. The average age of patients with shoulder syndromes was 56 and therefore, the number of self-referrals can be expected to be lower in comparison with the general patient population in physiotherapy practice. Pain severity might also explain the limited number of self- referrals among patients with shoulder syndromes. Pain is common in shoulder syndromes and he average score on the numeric rating scale for pain severity was seven for both referred patients and self-referrals. Kennedy et al. found a comparable level of pain severity in patients with soft tissue disorders 8 . Given the type of treatment offered in general practice, patients with severe pain might turn to a GP first. The difference might also be related to the onset of pain. Self-referrals more often involve complaints of a short duration 17 . In three quarters of the patients with shoulder syndromes, the symptoms developed gradually; a much higher proportion than seen in the general patient population (60%) 1 . Van der Windt et al. 20 showed that a relatively large proportion of patients with shoulder syndromes considered strain or overuse in usual activities to be the precipitating cause of their problems. This study also shows that many patients wait a long time before they visit a physiotherapist. Kennedy et al. also found that almost half of patients with soft tissue disorders of the shoulder wait more than three months before contacting a physiotherapist 8 . It seems worthwhile to bring this information to the attention of patients since both a gradual onset and long-lasting complaints might contribute to an unfavourable prognosis 21 . However, earlier physiotherapy intervention for more patients is more expensive. It is the responsibility of the profession to act on this. The new guideline on shoulder syndromes advises physiotherapists to use the classification of pain and functional limitations, as practiced by GPs. Given the limited value of clinical shoulder tests, even when combines 22 , this