Margit Kooijman

66 participating radiologists and orthopaedic surgeons found more disadvantages than advantages including false negative and positive results, lack of experience and not able to relate MSU to other additional imaging and insufficient education 3 . It has been shown that clinicians other than radiologists such as rheumatologists and orthopaedic surgeons are able to achieve comparable levels of diagnostic accuracy 22 . However, additional studies are required to confirm or refute these arguments. As with direct access physiotherapy, which was another shift in health services and possible substitution from GP care to physiotherapy care and also feared and criticised mainly by other health care professionals, reservations should be taken seriously 23 . The uptake of direct access was on the rise even before it was arranged officially and before (pilot) research was conducted on possible successes and failures. The utility of direct-access physiotherapy was supported by the high percentage of patients accessing this form of healthcare provision 23 . It appears that the profession anticipated and responded well on this changed demand. A similar situation now arises with MSU by physiotherapists; the uptake is on the rise, other health care professionals are sceptical and research is scarce 3 . At the same time, responding MSU physiotherapists appear enthusiastic at offering MSU; they think patients choose their practice specifically and are more satisfied. In addition, they think their treatment is more efficient and they are better able to cure patients. With direct access, new policy was made on education, reimbursement and interdisciplinary communication. The same is desired and required for MSU, also because of the large group of patients that comes via direct access. Objections and difficulties such as conflicting findings should be appointed so that they can be discussed and addressed as important training issues. Furthermore, more research is necessary. First on reliability, which would include intra- and interrater agreement between MSU physiotherapists mutually and between MSU physiotherapists and radiologists. Second, the effectiveness of additional MSU compared to the current situation should be investigated. This includes the desirability of MSU by the profession itself since a substantial group of practice owners indicated that they do not offer MSU, some for a very specific reason such as high costs whilst others mentioned no reason as to why they did not offer it. All in all, the professional need for an alternative for diagnosing patients with shoulder complaints and the possibilities that MSU offer for physiotherapists and their patients and eventually policy makers, should be explored more fully. Study limitations One of the purposes of current study was to explore the experiences of MSU physiotherapists with MSU within Dutch primary care settings in patients with shoulder complaints. Because little is known on MSU in primary care and in a physiotherapy setting particularly, questions were asked about the use of MSU in the general patient population (non shoulder). This was done not with the intention to compare both groups but to outline a framework to better understand the role of MSU in patients with shoulder complaints. However, since results show that MSU is used mainly for