Making Regulation Explicit in Osteopathic Thinking – and Beyond

Introduction

Since its inception, osteopathy has positioned itself as a treatment guided by reason rather than rule – focusing not on suppressing symptoms but on identifying and addressing the underlying cause of disease. Developed by Dr Andrew Taylor Still in the late 19th century, the profession emerged as a drug-free, hands-on approach to health, grounded in the belief that the body possesses inherent structural and physiological capacities for self-regulation and healing.

While grounded in osteopathy’s founding principles, the concepts explored in this article extend beyond osteopathy to inform manual therapy more broadly. Practitioners across disciplines – including physiotherapists, chiropractors, and integrative bodyworkers – are increasingly confronted with patients whose symptoms are not the result of physical trauma, but of chronic psychosocial stress. The patterns of a.o. musculoskeletal pain, fatigue, brain fog, and emotional distress they observe reflect persistent stress-related dysfunctions in regulatory systems, which in turn give rise to both physical and mental health conditions. Accordingly, this article contributes not only to the evolution of osteopathic reasoning, but also to a broader re-evaluation of clinical priorities across manual therapy in response to the health challenges of the 21st century.

At the heart of Dr A.T. Still’s philosophy was a deep appreciation for the interconnectedness of bodily systems, and his writings reveal a clinical method that began with identifying mechanical disruptions as the root cause of dysfunction. Structural interventions, in this context, were never an end in themselves. Rather, they served to liberate physiological processes – by restoring blood flow, relieving neural obstructions, and re-establishing what Dr A.T. Still described as the flow of “vital force.” As Lewis (2012) summarises, “The aim of treatment was not simply to normalise deranged structure but… to free nerve and blood supply… the vital force.” This emphasis on structure as a gateway to regulation reflected the health challenges of his time, where trauma, infection, and mechanical lesions were dominant.

Today, however, the landscape has changed. While structural dysfunction remains clinically relevant, many modern physical and mental health conditions arise primarily from chronic psychosocial stress. This stress disrupts the Central Autonomic Network (CAN), the Autonomic Nervous System (ANS), the Neuroendocrine System (NE-S), and the Immune–Inflammatory System (IIS), impairing the body’s adaptive capacities and contributing to functional somatic syndromes, mood disorders, and autoimmune conditions – even in the absence of structural pathology.

In light of this shift, the therapeutic sequence originally proposed by Dr A.T. Still warrants reconsideration. Emerging clinical and scientific evidence suggests that regulation – due to the changing aetiology of health problems – must now take precedence.
This article therefore proposes an evolution in osteopathic and broader manual therapy reasoning – one that explicitly recognises regulation as a foundational pillar alongside structure and function. By positioning regulation not merely as a by-product of structural correction but as a primary therapeutic focus, osteopathy and other manual therapy approaches can better meet the complex, stress-related challenges of modern healthcare. This reframing preserves the profession’s philosophical roots while advancing its scientific precision, clinical logic, and relevance in contemporary practice.

A Historical View: Self-Regulation in Dr A.T. Still’s Philosophy

While Dr A.T. Still never used modern terms like “autonomic nervous system” or “homeostasis,” his writings clearly reveal a deep appreciation for what we would now recognise as systemic regulation. Central to his philosophy was the idea that health depended on the unimpeded flow of vital forces throughout the body – primarily through the arterial system, but also via the nerves and cerebrospinal pathways. He famously stated, “The rule of the artery is supreme,” (Dr A.T. Still, 1902, p. 36) reflecting his conviction that vascular integrity was essential for physiological balance.

Dr A.T. Still also emphasised that if a part of the body was “shut off from the nerve current,” it would become diseased – highlighting his belief in the necessity of free neural transmission for health. In The Philosophy of Osteopathy (1899,p. 19), he wrote: “The cerebrospinal system is the source of all the vital forces… the centre from which vitality is dispensed to all parts of the body.”

Although framed in the language of vitalism, these observations reveal a systems-based perspective in which the nervous, vascular, and cerebrospinal systems worked together to coordinate health. Dr A.T. Still saw the nervous system not merely as a communication highway, but as a governing principle capable of influencing and regulating the entire organism. He further noted: “No artery, vein, or nerve is built wrongly. Nature makes no mistakes in their location, length, or purpose. When a part of the body is shut off from the nerve current, that part is sick.” (Still, 1899, p. 163)

To Dr A.T. Still, disease was the result of obstruction – not only physical, but functional. He believed that when the circulatory or neurological pathways were disrupted, the body lost its capacity to regulate and heal itself. Manual intervention, therefore, was not just about correcting structural misalignments, but about restoring what he considered the vital flow of ‘life force’ – which we might now interpret as regulatory signalling across integrated physiological systems.

It is therefore evident that regulation – though not explicitly termed as such – was foundational in Still’s vision. However, as osteopathy became more formalised, particularly in the mid to late 20th century, its focus increasingly shifted toward biomechanics and the structural model as therapeutic priorities in their own right. In Europe especially, this transition was reinforced by the alignment of osteopathic education with physiotherapy programmes, which often prioritised orthopaedic reasoning and manual techniques grounded in anatomical and kinesiological frameworks. While this alignment brought scientific legitimacy and broader professional recognition, it also contributed to sidelining the subtle, systems-oriented view of regulation that underpinned Dr A.T. Still’s original philosophy.

The Structure–Function Tenet: A Posthumous Codification

One of the key principles on which osteopathy is based today – “structure and function are reciprocally interrelated” – was not introduced by Dr A.T. Still himself. It emerged in the early 20th century as part of efforts to codify osteopathic principles and distinguish the profession from allopathy and chiropractic. While aligned with Dr A.T. Still’s holistic perspective, the tenet came to emphasise the dynamic interplay between anatomical structures (such as bones, muscles, and organs) and the specific physiological functions of those parts.
It helped osteopathy gain legitimacy in scientific and academic circles, aligning it more closely with anatomy, kinesiology, and pathology. However, this codification may have inadvertently reduced the richness of Dr A.T. Still’s original philosophy – especially his emphasis on regulation.

Today, many osteopaths continue to work within a structure–function principle grounded in 19th- and 20th-century kinesiological and biomechanical frameworks – often without accounting for the evolving aetiology of contemporary health conditions, many of which no longer stem from physical trauma but from an evolutionary mismatch between biology and culture, resulting in chronic disruptions of autonomic regulation.

The Modern Mismatch: Chronic Stress, Dysautonomia, and Loss of Adaptability

We live in a world vastly different from that of Dr A.T. Still and the context in which The Osteopathic Concept was published in 1953. Today’s predominant health challenges – including musculoskeletal pain – are no longer primarily rooted in physical trauma or anatomical lesions. Instead, they increasingly stem from chronic psychosocial stress and its impact on the body’s ability to regulate itself. This results in persistent maladaptive patterns across the EARS.

In Why Zebras Don’t Get Ulcers, neuroscientist and stress researcher Robert Sapolsky outlines how chronic stress affects the body’s regulatory systems:

• Dysregulation of the CAN
  
• Overactivation of the HPA axis and cortisol dysrhythmia (NE-S)
• Sympathetic dominance or vagal withdrawal (ANS)
• Disrupted circadian rhythms, immune activation, and emotional dysregulation (IIS)

and how this translates into:

• Musculoskeletal pain without trauma, headaches, digestive problems…;
  
• Non-restorative sleep, brain fog, emotional lability, anxiety and depression;
• Digestive disturbances, palpitations, fatigue, or medically unexplained symptoms and multimodal disorders without clinical explanation.

Symptoms once attributed to mechanical dysfunctions are now understood, in many cases, as expressions of chronic stress-related dysautonomia. In prolonged cases, this can culminate in what I define as an autonomic lesion – a persistent dysfunction in the body’s regulatory hierarchy (CAN, ANS, NE-S, and IIS), where neural circuits have undergone structural and functional changes that do not self-correct without targeted therapeutic intervention aimed at re-establishing regulatory coherence.

If the origin of disease has shifted from predominantly physical causes to disturbances in regulatory function, and if – as Dr A.T. Still asserted – treatment must be guided by reason rather than rule, then the osteopath’s search for causality can no longer begin solely with structural analysis. Focusing exclusively on the structure–function relationship risks overlooking the true onset in many modern cases. In today’s evolving clinical landscape, diagnostic reasoning and therapeutic intervention must also consider the level of regulation – depending on the patient’s history, presenting symptoms, and the context revealed during anamnesis. 

In light of this shift, it becomes necessary to critically reconsider the scope of the structure–function principle.

Expanding the Structure–Function Paradigm: A Case for Making Regulation Explicit

However, rather than discarding the structure–function principle, this article proposes an evolution of it – one that explicitly integrates regulation as a foundational dimension within the structure–function interrelationship.

By positioning regulation at the base of an inverted clinical pyramid, we affirm its foundational role in supporting structural and functional integrity – particularly in the context of 21st-century health challenges driven by chronic stress and systemic dysregulation. This reframing gives rise to a revised clinical hierarchy:

• Regulation – Restore autonomic balance, coherence, and adaptability
• Structure – Address restrictions, lesions, and anatomical dynamics
• Function – Enable structures to perform their physiological roles effectively

In other words, when symptoms arise from autonomic dysfunction or what can be termed an autonomic lesion – the root cause – regulation must be addressed first, prior to treating the structural and functional consequences. In fact, restoring regulatory balance may prove beneficial as the initial step in any therapeutic process, regardless of the perceived onset of the patient’s condition.

Expanding the traditional structure–function principle to explicitly include regulation responds to the pressing demands of our fast-changing and stress-laden world. The primary impact of modern challenges is often not structural in nature but regulatory – disrupting the body’s ability to adapt and maintain balance. This evolution has relevance beyond osteopathy and extends to the broader field of manual therapy. It invites physiotherapists, chiropractors, craniosacral therapists, and practitioners of fascia-focused modalities to re-evaluate their treatment priorities and integrate regulatory assessment as a core component of care.

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Summary: Why Regulation Must Be Made Explicit

Because it honours Dr A.T. Still’s original vision
Dr A.T. Still taught that osteopathic practice was not to be governed by rules, but by two complementary principles: cause and effect, and nature’s inexorable drive to express health. In other words, treatment must be guided by reason. Given the shifting origin of disease from physical trauma to regulatory dysfunction, it is reasonable to conclude that restoring the body’s inherent healing capacity must now begin with regulation – the very source of imbalance in most modern health problems. Integrating regulation as a clinical pillar also aligns with Still’s enduring tenet that “the rule of the artery is supreme.” Today, it is not structural obstruction but autonomic dysregulation that most often compromises blood flow. To remain faithful to Still’s vision of enabling the body to heal itself, we must recognise that in the 21st century, liberation begins not with structure, but with the restoration of regulatory coherence. Regulation is now the logical starting point for clinical reasoning and therapeutic intervention.

Because it aligns with the lived experience of patients
In contemporary clinical practice, patients increasingly present without a clear or identifiable onset of symptoms. Complaints often arise abruptly – sometimes overnight or following routine physical activity – and are frequently accompanied by multiple, seemingly unrelated symptoms. It is now common for musculoskeletal discomfort to occur alongside fatigue, cognitive fog, emotional lability, tension, or a sense of disconnection. Such multimodal symptom patterns seldom reflect isolated biomechanical dysfunctions. Rather, they suggest disturbances in the body’s regulatory systems, frequently linked to sustained psychosocial stress. This stress – driven by a growing mismatch between human biology and modern cultural environments – disrupts autonomic, neuroendocrine, and immune balance. By explicitly integrating regulation into clinical reasoning, manual therapists can more effectively identify the root causes of dysfunction and align their diagnostic and therapeutic strategies with the complex realities of 21st-century health – ultimately enhancing both treatment precision and patient outcomes.

Because health depends on regulation
Before physiological function can improve – and before structural corrections can hold – the body must be capable of adapting and manage change. This adaptive capacity is governed by the integrity of its regulatory systems. When these systems are dysregulated, even the most skilful manual interventions risk being temporary or ineffective. True therapeutic progress requires first restoring coherence within the EARS, allowing the body to re-establish internal balance and respond constructively to further treatment. In this light, regulation is not secondary – it is the precondition for healing.

Conclusion

Making regulation explicit within osteopathic thinking is not a departure from tradition – it is a refinement and maturation of it. Although Dr A.T. Still may not have used the term regulation, his writings consistently emphasised the vital role of neurological, circulatory, and systemic coordination in sustaining health. He also never claimed that all disease was caused by bony displacements. On the contrary, he acknowledged that his science would be incomplete “were it only concerned in irregularities in the framework,” recognising that other influences – including emotional shock, bereavement, loss of property or friends, and extremes of weather – could initiate or sustain abnormal functioning (Lewis, 2012).

In today’s evolving clinical landscape, shaped by chronic stress, dysautonomia, and an accelerating mismatch between biology and culture (i.e. environment), it is imperative that these broader contributors to dysfunction are brought to the forefront of clinical reasoning.
By adopting a triadic model of Regulation – Structure – Function, we take osteopathic philosophy back to its origin and align it with contemporary science, practice and the lived experience of patients. Adding regulation reflects the clinical reality that without autonomic coherence and systemic adaptability, structural interventions often fail to yield sustainable functional change.

This represents not a semantic adjustment, but a necessary paradigm shift in clinical reasoning and practice. In an era where pathology is increasingly rooted in dysregulation rather than anatomical lesion, the capacity for dynamic regulation emerges as the cornerstone of resilience, adaptability, and recovery.

To honour osteopathy’s original commitment to treating the whole person and activating the body’s self-healing capacity, we must now add regulation as pilar for care – not as an afterthought, but include it explicitly to the structure-function principle as the active interface between environment, adaptation, and health. In doing so, we ensure that osteopathy – and manual therapy more broadly – continues to evolve in both relevance and rigour: grounded in history, but responsive to the physiological and psychosocial realities of the 21st century.

Authors note:

The clinical reasoning and regulatory framework presented in this article stem from the development of The Reaset Approach – a therapeutic methodology created by osteopath and Fitfull Futures Explorer Tom Meyers, and refined over more than 15 years in response to a clear shift in the aetiology of his patients’ health issues: from predominantly physical to increasingly psychosocial in nature. By prioritising the treatment of stress-related autonomic imbalances before addressing structural or symptom-specific dysfunctions, patient outcomes improved significantly. This experience gave rise to The Reaset Approach. Today, Tom trains manual therapists internationally in this hands-on, science-informed treatment modality, developed to address the evolving roots of dysfunction and restore autonomic balance as a foundation for sustainable wellbeing.

With this article, Tom addresses the osteopathic community directly – inviting it to reason afresh about cause and effect in light of today’s health challenges, and to consider regulation not as an afterthought, but as a clinical priority that restores integrity to the profession’s founding principles.

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References

• Griffiths, P. E., & Bourrat, P. (2023). Integrating evolutionary, developmental and physiological mismatch. Evolution, medicine, and public health, 11(1), 277–286. https://doi.org/10.1093/emph/eoad023
  
• Lewis, J. (2012). A.T. Still – From the dry bone to the living man. Gwynedd, Dry Bone Press
• Meyers, T. (2019). The effect of the “Reaset Approach” on the autonomic nervous system, neck-shoulder pain, state-trait anxiety and perceived stress in office workers: A randomised controlled trial. MSc. Thesis. Dresden International University (DIU) and Osteopathy Schüle Deutschland (OSD). https://bit.ly/47r8juO
• Sapolsky, R. M. (2004). Why zebras don’t get ulcers: The acclaimed guide to stress, stress-related diseases, and coping (3rd ed.). New York, NY: Henry Holt and Company.
• Still, A. T. (1899). The philosophy of osteopathy. Kansas City, MO: Hudson-Kimberly Publishing Co.
• Still, A. T. (1902). The philosophy and mechanical principles of osteopathy. Kirksville, MO: Journal Printing Company.

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This article was written by Tom Meyers with the assistance of ChatGPT, blending personal insights and advanced AI support to create a compelling and impactful message.