Over the decades, I have developed an extensive referral network. Many of my clients can benefit from other services in addition to what I can offer. Other practitioners have their areas of expertise and often recognize that at any given time, their clients may need additional services, including what I can provide.

I refer to some practitioners who also refer to me; there are others I refer to extensively who have never made a referral to me. I enjoy receiving referrals, but referring my clients to others is never dependent on reciprocity, it is all about the well-being of the client. After practicing in the same locality for decades, most of my new clients now come from referrals from former clients, with some from other health-care providers – notably a few MDs with alternative orientation. This referral network has developed organically over time. Some practitioners in the network are ones I have seen for my own health-care needs. Clients or colleagues recommended others.

Another local structural integrator (who is a good friend) took many other practitioners to lunch to educate them about his work, and to learn about their particular expertise. He found this successful in building his practice. I have not done this, but would consider doing so if I were in a position to build a new practice.

When sharing information with other practitioners, I sometimes send along notes with clients. Physicians regularly send me radiology reports, and occasionally surgical reports. Fax transmissions are useful for these exchanges, for rarely is there time for collaboration by phone. In all sharing of client information, HIPPA regulations concerning confidentiality must be strictly observed, and this largely excludes the use of email.

Client needs which necessitate a referral to another practitioner may come to light at any time: when completing an intake questionnaire, during the first session, during later sessions, at the end of a series of work, or any amount of time after our work is concluded.

In alphabetical order, here are some of the frequent referrals that I make:

Chiropractors: This group has reported that after their patients receive structural integration work from me, they are easier to adjust and the adjustments are more likely to hold. I find that in some situations, if a chiropractor relieves pressure on a nerve in a client of mine, it is easier for me to do my work. There is considerable diversity of practice among chiropractors. I refer to those whose work I know well, or who have stellar reputations in the community. I often refer to upper cervical specialists, and also to certain chiropractors who are well trained in more methods in addition to high-velocity low-amplitude (HVLA) thrust.

Compounding Pharmacists: Pain and sleep deprivation form an ugly feedback loop. Pain disturbs sleep, and disturbed sleep leads to bodily discomfort. Some clients with chronic pain have very disturbed sleep patterns. As practitioners, we want to organize their bodies so they can be more comfortable, but often an important stepping-stone toward healing is adequate nighttime pain control so they can get adequate sleep. Some compounding pharmacists are well educated about compounded topical analgesics. These are prescriptions where a mix of several nonopioid medications is put into a cream, thus able to be applied to painful areas. Significant pain reduction can be achieved with several advantages to the client. Because the medication is absorbed through the skin, the blood concentration of the drugs remains low, so there is less potential for liver, kidney, and stomach damage compared to oral administration. Also, the addictive tendency of opioid medication is avoided. While a physician’s prescription is necessary for these drug preparations, the client having a discussion with a pharmacist well versed in topical analgesics is sometimes a good starting place.

Cranial Therapists – Pediatric/Neonatal: I am trained in three different directions of cranial manipulation, including training in pediatric and neonatal cranial manipulation. However, I get few newborns in my practice, so if I encounter a complex or difficult situation, I refer to other practitioners who work with babies on a daily basis.

Dentists: Many clients have dental and/or oral situations that are limiting their ability to be well organized and healthy in their bodies. I refer to several specialties including: general dentistry, TMJ specialists, obstructive sleep apnea appliance specialists, orthodontists, endodontists, and oral surgeons.

Emergency Room or Urgent Care: Clients have arrived at my office with a range of conditions that warrant prompt medical attention including: injuries from a bicycle crash on the way to my office, bones that have been broken for several days, acute appendicitis, dizziness and confusion that turned out to be a brain tumor(!), pleurisy, urinary tract infections, and kidney stones. When in doubt about proceeding with treatment, refer clients to an urgent care facility or their primary care physician. Err on the side of caution.

Functional Neurologists: These physician specialists make detailed analyses of central nervous system function and provide clients with activities and exercises to wake up and connect parts of the brain that have been functioning suboptimally. Functional neurologists have helped many clients with sensory integration challenges, balance problems, learning difficulties, and much more.

Massage Therapists: Clients occasionally ask me for referrals to massage therapists, and I am happy to refer them to people I know who do quality work.

Mental Health Professionals: Some clients tell me about, or manifest, emotional challenges, either situational or long term. Some ask me for referrals to mental health professionals. For others, I gently work the topic into the conversation, and if they are receptive I offer referrals to professionals I trust and whose skills may match the client’s needs.

Naturopaths: Many naturopaths are skilled at diagnosing and treating pesky digestivesystem problems. Other naturopaths are skilled homeopaths. Most are able to offer good nutritional counseling. Other naturopaths develop skills in a wide range of specialties. I have gotten to know the strengths of many naturopaths and refer accordingly.

Obstetricians/Gynecologists: Some women tell me about reproductive system symptoms that should be looked at by a doctor. Occasionally I see situations working viscerally that lead my thinking in this direction. For example, a client came to me with a mild foot injury, which had not healed after two years. Exploring this, it was discovered that she had a very large uterine fibroid tumor lying on top of her iliac vasculature on the side of the problematic foot. If she lay supine, she promptly had more foot pain. I had her lie in that position and let the foot pain start. I then manually shifted the fibroid off the vasculature and the pain abated. She had been debating for some time whether to have a hysterectomy. After this demonstration, she made the decision to have the hysterectomy. This excision included an 800-gram fibroid. When the pressure on the vasculature to her left leg was relieved, her foot healed.

Optometrists: Clients sometimes arrive with very out-of-date vision prescriptions for their eyeglasses, which are causing them eye strain and often neck strain. I have particularly noticed that if the astigmatic axes have shifted in a client’s eyes, he may be holding his head in a tilted position to compensate for it. Other clients need specialized eyeglasses for particular occupational situations. For example, an optometrist explained to me why most computer users should not wear progressive lenses while at the computer, but should instead have a dedicated pair of computer glasses. Progressive lenses provide a narrow band of vision useful at a computer that requires the neck to be held in significant extension. I recommend to clients that they seek additional help from vision specialists if eyestrain or headaches are a problem for them.

Orthopedic Surgeons: Some clients have arthritic changes in joints, which can benefit from surgical approaches. One indicator for an evaluation of this type is when our work increases range of motion, but the joint pain does not decrease or even increases. For the hip joint, the FABER test is also an indicator for an orthopedic exam.

Physical Therapists: I have no specific training in therapeutic exercise or stretching. Over the years, I have picked up a little of this and can offer clients some basic techniques. For any more challenging or complex situations, I refer to selected physical therapists whose work I trust.

Podiatrists: Podiatrists are licensed to practice medicine in the foot, ankle, and lower leg up to the knee. I refer medical problems in this part of the body to podiatrists. I am particularly enthusiastic about the work of Portland, Oregon podiatrist Ray McClanahan, whose website is www.nwfootankle.com. He has a very insightful understanding of the toes and the role they play in the structure and well-being of the whole person. I highly recommend visiting his information-rich website.

Primary Care Physicians: Clients frequently mention health-care needs that should be addressed by a physician. This may be as simple as not having had a regular physical in several years, or can be a wide range of other health concerns. Sometimes I observe things and believe that a client would benefit from getting medical advice, for example, an asymmetrically shaped mole that appears to be increasing in size. In those situations, I strongly urge the client to seek medical attention.

Sleep Doctors: Sleep disorders are epidemic. It is estimated that one-third of the population meets full diagnostic criteria for some kind of sleep disorder. Beyond that third of the population, there are more people who just don’t sleep well. I explore sleep issues with all clients and, when useful, I educate them about sleep hygiene. For more serious issues, I refer clients to physicians trained in sleep disorders. Among sleep disorders, sleep disordered breathing in its various forms [central apnea, obstructive apnea, and upper airway resistance syndrome (UARS)] is common in the population as a whole and quite overrepresented in the client population with which I work, which is chronic-pain clients. In the general population, the incidence of obstructive sleep apnea alone is estimated at 20% of the population. With sleep apnea in its various forms, the combination of frequent partial waking and critically low oxygenation during the night is quite damaging to all tissues, and particularly to the nervous system. I specifically probe these issues with all clients, and it is a rare week during which I do not ferret out at least one case of sleep apnea. Usually the client was either not aware of it, or was discounting its importance. Proper diagnosis and treatment of these disorders by a sleep doctor improves tissue health, which allows my work to be more effective.

Sports Medicine Physicians: Physicians specializing in sports medicine are good at diagnosing musculoskeletal complaints, both axial and appendicular. They are often trained in prolotherapy, platelet-rich prolotherapy (PRP), stem-cell therapy, and other cutting-edge methods. If a client’s joint or spine-related problem is not resolving with my work, or if the symptoms are becoming more severe, I may refer the client to selected sports medicine doctors whom I know to be ace diagnosticians. One specific situation is where there is demonstrable ligament laxity that does not resolve by loosening related fibrosities; then I refer the client to a sports medicine doctor or other specialist to be evaluated for possible prolotherapy or PRP.

Conclusion

Once upon a time, long, long ago, when I was young and naïve, I had an idea that I could learn everything. Since then, I have learned more about the dimensions of a human lifetime. Just to learn everything there is to know about structural integration has turned out to be more than a onelifetime project.

I am a member of the Pain Society of Oregon and the Western Pain Society. In these richly multidisciplinary groups, we educate each other at our monthly meetings and annual conferences about both the outline and leading edge of each of our practices. Thus we can each recognize the signs of more kinds of issues and make appropriate referrals. I encourage those working in other geographic regions to find or found similar organizations. Jeffrey Burch was born in Eugene, Oregon in 1949, and grew up there except for part of his teens in Munich, Germany. He was educated at the University of Oregon, Portland State University, and the University of Pavia, Italy, earning bachelor’s degrees in biology and psychology and a master’s degree in counseling. Jeffrey received his Rolfing certification in 1977 and his advanced Rolfing certification in 1990. He trained extensively in cranial manipulation with French etiopath Alain Gehin, and in craniosacral therapy with the Upledger institute.

Jeffrey trained to the instructor level in visceral manipulation under Jean-Pierre Barral and his associates. He has made substantial innovations in visceral manipulation particularly for the thorax. Jeffrey has also developed groundbreaking new jointmobilization techniques. He first practiced in London, England, and later in Anchorage (Alaska), Seattle (Washington), and Honolulu (Hawaii) before returning to his native Oregon in 1989, where he continues to practice and to teach continuing education courses. A Team Approach[:]