Margit Kooijman

Shoulder vignettes | 49 Discussion This vignette study which aims to find potential leads to improve treatment of patients with shoulder pain in primary care shows that the degree to which general practitioner and physiotherapist management correspond with each other seems to depend on the type of shoulder pain involved. Regarding subacromial complaints (vignette 1) or an acute rotator cuff tear (vignette 2), the majority of both clinicians generally agreed on preferred treatment. The scenarios of the patient with capsulitis (vignette 3 and 4), especially the late presentation, showed more variation in responses both between- and within groups. Compared to earlier research on Australian general practitioner and rheumatologist care of the same patients with shoulder pain presented in current study, Dutch general practitioners and physiotherapists adhere to their guidelines to a much larger degree 15 . Except in the case of the late presentation of capsulitis, there was less reliance on unnecessary imaging and referral to secondary care and more agreement on the preferred treatment. Nevertheless, a recent study in physiotherapy practices in the Netherlands confirmed existing estimations that around 60% of patients recover in six months and although this is a bit higher than the 21-51% reported in general practice, it still leaves a large group of patients with ongoing shoulder problems 5 . It is interesting to look into the aspects of treatment in which clinicians diverge from each other and best available evidence. First, despite relatively low reliance on imaging and referrals to specialists, general practitioners and physiotherapists choose a high rate of interventions. For example, in all scenarios except the early presentation of capsulitis, general practitioners tend to prescribe or advise analgesics although impairment and not pain is the main complaint. In the second scenario of acute rotator cuff tear referrals for imaging and/or specialist care suggest a correctly made diagnosis, however many also refer for physiotherapy. Likewise, physiotherapists indicate additional investigations are necessary but at the same time start treatment themselves, often targeted at mobilization which is contradictory to their appropriate recognition of possible tissue damage. This becomes clearer in the scenario of the late presentation of capsulitis in which general practitioners initiate all types of different treatment and thus diverge from each other. Additionally, evidence suggests that these complaints usually are self-limiting and that in the long run no type of treatment is favourable above another, including placebo 16,17 . Although physiotherapists seem to be more aware of the problem at hand as they more often indicate the correct prognosis and opt for fewer referrals to general practice, they too report to intervene. A high rate of referrals back and forth could indicate willingness to collaborate in the patient’s best interest, as it appears to do in the scenarios of subacromial complaints and acute rotator cuff tear. High intervention rates could also suggest insecurity on the right management including keep/refer decision-making.