STILL RELEVANT?  |   July 2018
The Rule of the Artery Is Supreme. Or, Is It?
Author Notes
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Felix J. Rogers, DO, Henry Ford Wyandotte Downriver Cardiology, 23050 West Rd, Suite 120, Brownstown, MI 48183-1470.Email:
Article Information
Cardiovascular Disorders / Preventive Medicine
STILL RELEVANT?   |   July 2018
The Rule of the Artery Is Supreme. Or, Is It?
The Journal of the American Osteopathic Association, July 2018, Vol. 118, 429-430. doi:
The Journal of the American Osteopathic Association, July 2018, Vol. 118, 429-430. doi:
Physicians are drawn to axioms—short statements that become guiding principles. When they express a truth and challenge us to be vigorous in our thinking, they serve us well. 
The teachings of Andrew Taylor Still have served our profession well, but his initial followers and the osteopathic profession as a whole often truncated his writings into pithy phrases to clarify the tenets and principles of the school of medicine that he founded. It helps to consider the statements in the context of his writing and of the medicine of his time. To address the question whether the saying is “still relevant,” we need to apply 2 tests: (1) Does this saying spur us to critical thinking on this topic? and (2) Has his perspective stood the test of time over a century of medical progress? 
One widely quoted aphorism attributed to Dr Still is “the rule of the artery is supreme.” (Although this statement did not appear in Dr Still's writing, similar quotes did, such as “the rule of the artery is absolute, universal, and it must not be obstructed.”1[p219]) In its historical context, this widely quoted aphorism may have arisen from an early dispute with the chiropractic profession,2(pp81-84) which proposed that bony impingement on nerves was the primary consequence of spinal misalignment. The osteopathic medical profession, however, believed that it was external pressure on arteries that led to adverse effects. 
When Dr Still founded osteopathy in the late 1800s, arteries were believed to be passive conduits to blood flow. It would be several decades before the role of atherosclerosis was described, and several decades after that before the dynamic role of the vascular endothelium was discovered. In Dr Still's time and our own, the central role of the arterial blood supply seems so obvious that many do not examine the concept critically. 
Peripheral artery disease (PAD) involves atherosclerotic disease of the aorta, iliac, and lower extremity arteries. An important implication of PAD is that it is a marker of a generalized, diffuse process of atherosclerosis, and it is therefore a predictor of subsequent heart attack and stroke. Patients with PAD have a 3- to 4-fold increase in risk of cardiovascular events, even in patients with asymptomatic PAD.3 The 5-year mortality rate is 15% to 20%, and most of it is from cardiovascular causes.4 Current primary prevention with aggressive risk factor modification can reduce the morbidity and mortality of myocardial infarction and stroke substantially. 
The key aspects in the treatment of patients with PAD involve exercise, optimal medical management, and endovascular therapy. 
Current expert consensus documents recommend an “endovascular first” approach for the majority of patients requiring revascularization.5,6 Patients with PAD have a major decrease in exercise performance, which is much more complex than can be interpreted by an assumption that the rule of the artery is supreme. Ten percent to 30% of patients have classic claudication, 20% to 40% have atypical leg pain, and 50% are asymptomatic.4 
The overall goal in treating patients who have exercise limitations is to improve exercise performance, quality of life, and functional status. Exercise training has a well-established benefit after a typical 12-week training program.7,8 It directly modifies several abnormalities in PAD, including improved skeletal muscle metabolism, endothelial function, and gait biomechanics.9 Physical activity in patients with PAD is associated with a decrease in all-cause and cardiovascular mortality.10,11 
Both exercise and revascularization improve patient exercise performance, but by different mechanisms. Revascularization primarily improves exercise blood flow, whereas exercise training induces improved skeletal muscle mitochondrial oxidative metabolism, improved endothelial function, and more efficient biomechanics of walking. 
Because the presence of PAD, even when patients are asymptomatic, is a marker of increased cardiovascular risk, another major goal of treatment is optimal medical therapy. The first challenge is for the patient to discontinue tobacco use. Discontinuation of smoking is the most important lifestyle modification to prevent critical limb ischemia. Pharmacologic approaches include cilostazol, angiotensin-converting enzyme inhibitors, statins, and antiplatelet agents. The comprehensive approach to PAD should include an exercise program, guideline-based medical therapy to lower cardiovascular risk, and, when revascularization is indicated, an endovascular first approach.6 
The application of the axiom “the rule of the artery is supreme” to the treatment of patients with PAD would be a disservice. Peripheral artery disease is too complicated for such an approach, and it risks the opportunity to treat the patient comprehensively, improve functional status, prevent critical limb ischemia, and prevent myocardial infarction and stroke. 
Still AT. Autobiography of Andrew T. Still With a History of the Discovery and Development of the Science of Osteopathy. . Kirksville, MO: published by the author; 1897:219.
Palmer DD, Palmer BJ. The Science of Chiropractic: Its Principles and Adjustments. Davenport, IA: Palmer School of Chiropractic; 1906.
Leng GC, Fowkes FG, Lee AJ, Dunbar J, Housley E, Ruckley CV. Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study. BMJ. 1996;313(7070):1440-1444. [CrossRef] [PubMed]
Olin JW, White CJ, Armstrong EJ, Kadian-Dodov D, Hiatt WR. Peripheral artery disease: evolving role of exercise, medical therapy, and endovascular options. J Am Coll Cardiol. 2016;67(11):1338-1357. doi: 10.1016/j.jacc.2015.12.049 [CrossRef] [PubMed]
Rooke TW, Hirsch AT, Misra S, et al Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(14):1555-1570. doi: 10.1016/j.jacc.2013.01.004 [CrossRef] [PubMed]
Tendera M, Aboyans V, Bartelink ML, et al. European Stroke Organisation, ESC Committee for Practice Guidelines. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(22):2851-2906. doi: 10.1093/eurheartj/ehr211 [CrossRef] [PubMed]
Hiatt WR, Regensteiner JG, Hargarten ME, Wolfel EE, Brass EP. Benefit of exercise conditioning for patients with peripheral arterial disease. Circulation. 1990;81(2):602-609. [CrossRef] [PubMed]
Hiatt WR, Wolfel EE, Meier RH, Regensteiner JG. Superiority of treadmill walking exercise versus strength training for patients with peripheral arterial disease; implications for the mechanism of the training response. Circulation. 1994;90(4):1866-1874. [CrossRef] [PubMed]
Hiatt WR, Regensteiner JG, Wolfel EE, Carry MR, Brass EP. Effect of exercise training on skeletal muscle histology and metabolism in peripheral arterial disease. J Appl Physiol (1985). 1996;81(2):780-788. [CrossRef] [PubMed]
Chang P, Nead KT, Olin JW, Myers J, Cooke JP, Leeper NJ. Effect of physical activity assessment on prognostication for peripheral artery disease and mortality. Mayo Clin Proc. 2015;90(3):339-345. doi: 10.1016/j.mayocp.2014.12.016 [CrossRef] [PubMed]
Sakamoto S, Yokoyama N, Tamori Y, Akutsu K, Hashimoto H, Takeshita S. Patients with peripheral artery disease who complete 12-week supervised exercise training program show reduced cardiovascular mortality and morbidity. Circ J. 2009;73(1):167-173. [CrossRef] [PubMed]