CF 364: Spinal Manipulative therapy And Stroke & Metformin For Knee Osteoarthritis Today we’re going to talk about SMT And Stroke & Metformin For Knee Osteoarthritis But first, here’s that sweet sweet bumper music  

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  OK, we are back and you have found the Chiropractic Forward Podcast where we are giving evidence-based chiropractic a little personality and making it profitable. We’re not the stuffy, elitist, pretentious kind of research. We’re research talk over a couple of beers. So grab you a bushel.  I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.  I’m so glad you’re spending your time with us learning together.  Chiropractors – I’m hiring at my personal clinic. I need talent, ambition, smarts, personality, and easy to get along with associates. If this is you and Amarillo, TX is your speed, send me an email at [email protected] If you haven’t yet I have a few things you should do. 

You have found yourself smack dab in the middle of Episode #364 Now if you missed last week’s episode, we talked about Lateral Lumbar Stenosis & Manual Therapy Combined With PT Make sure you don’t miss that info. Keep up with the class. 

On the personal end of things…..

Man, what have I been up to? Let’s see, I went to Charleston weekend before last, we had the big MCM Mastermind quarterly meeting with Dr. Kevin Christie and other incredibly smart, high level docs.  I get plenty fromt he speakers but the majority of what you get is with the side, private discussions with fellow group members and the friendships and the network that builds out from there.  I came back from this one with a solid direction to add $50k-$100k per year to the practice. I’d say that’s worth the the yearly membership and travel finances. Very much worth it. 

Outside of that, I’ve been doing a pretty deep dive on AI lately and how it can add to my life and help with the clinic. It’s just stunning if I’m being honest. It surprises me every single day, basically.  I’ve been testing them all but have really settled in on ChatGPT, for now at least. It seems to have the edge for me. It named itself Chippy. I helped it but yeah….Chippy is coming in pretty damned handy these days.  Here are some of what Chippy has been up to:

AI is amazing. Chippy is astounding. Yeah, AI worries me. I have concerns about whether the VoiceOver business will even be a business in 5 years. I have concerns about the bots taking over the world some day. I have all of those worries. But if we don’t use it, we fall behind. If we don’t use it, we get beat by those that embraced it. I truly believe that.  I’m using it. I’m just saying thank you and please so that if they do take us over, I’ll be one of the last to go. : ) Outside of that, I’m still walking through the steps toward closing on the sale of 60% of the practice. We’re bringing in a partner and I can’t wait.

They’ll do HR, billing, collecting, and all of the soul-sucking part of it.  I’ll get a percentage of my collections off of my services. I’ll get 40% of the profits of the clinic, and I’ll get the loan payment from the sale every month until the balance is paid off.  I have their guarantee that issue #1 is to get an associate chiropractor in here to take some heat off of myself.

Here’s my deal and listen up close, mi amigos. 

I have a friend that got cancer in his late 60s. He died last year. Nobody would buy his clinic so, at the end of the day, his wife sold off the equipment and that was it.  I’ve had COVID 5-6 times now and I’ve only missed one day of work. That’s not fair to me, my family, my patients, or my staff when the entire operation depends so much on me being in the office working on patients personally.  I think I’m irresponsible if I don’t do my part to make it more stable and more sustainable when I am not present. When I’m not in the clinic personally.

So that’s a big part of what I’m trying to accomplish here. 

I have two TCA colleagues that have done this with this company already and they both said they work less and make more. I went to the owner’s retreat in February and met their other 11 owners. They all said they’d do it again and wish they’d have done it sooner. 

So, I’m doing it for my future, for stability, for longevity, for my sanity, and for a higher quality of life. My life at this point is a good life. But it’s not the life I would imagine or desire for myself. Not yet anyway. Once I get some support, life improves.  If you want more info to see if that’s something you’d like to explore, give me a shout at [email protected]. 

Item #1

Our first one today is by my good friend Dr. Steve Brown out in Gilbert, AZ. Dr. Brown has been an expert witness in several court cases involving DCs and strokes. I met Dr. Brown in Chicago a year and half or so at my Forensics Diplomate conference. He was attending and speaking at the event.  In fact, I was on the elevator talking to someone and a voice from the back of the elevator said, “Hey, aren’t you the guy with the podcast?”

Or something like that. Lol.  That started a friendship and Dr. Brown is not just a buddy now but a go-to source for everything SMT or stroke related. He gets beat up by some other DCs that don’t like what he has to say but at the end of the day, he’s a proponent of educating and of DCs being educated thoroughly so that you can avoid the hot seat. So, ignore him at your peril. 

Dr. Brown has 10 peer reviewed studies under his belt now so the dude knows his stuff. When I get my life together and have an opportunity to start having guests on the podcast again, he’ll be the first one. 

With that said, let’s dive into his latest called, “Stroke vs. toxin release after chiropractic spinal manipulation: A plausible hypothesis” by Dr. Steven Brown and published in Medical Hypostheses in May of 2025 and Shitake Mushrooms….that’s hot. Remember, the citations can be found at chiropracticforward.com under this episode. 

Stroke vs. toxin release after chiropractic spinal manipulation: A plausible hypothesis, Medical Hypotheses, Volume 198, May of 2025, 111629, ISSN 0306-9877, https://doi.org/10.1016/j.mehy.2025.111629. (https://www.sciencedirect.com/science/article/pii/S0306987725000684)

Why They Did It

Multiple chiropractors report that some patients experience symptoms of dizziness/vertigo, nausea/vomiting, neck pain, headaches, sweating, fatigue, diarrhea, and fever after spinal manipulation. These chiropractors attribute these symptoms to toxic release caused by spinal manipulation. The objective of this study was twofold. First, to evaluate the research supporting the claim that these symptoms after spinal manipulation are the result of toxin release. Second, to propose a plausible alternative hypothesis for these symptoms of alleged toxin release.

How They Did It

PubMed, Index to Chiropractic Literature, and Google Scholar were searched from inception to November 2024. 

What They Found

This is a novel hypothesis. No peer reviewed studies were found supporting or refuting the proposition that alleged toxin release following neck manipulation is instead a minor ischemic stroke. However, the proposition that cervical spine manipulation can cause a thromboembolic stroke when performed in the presence of an existing undiagnosed cervical artery dissection is not novel.  This mechanism of causation has been supported in 15 peer reviewed studies by researchers from neurology, Courses reviewing the body of research on the potential causal relationship between cervical spine manipulation and stroke should be mandatory for chiropractic students.  Mandatory annual continuing education courses on the adverse effects of spinal manipulation, including stroke, are indicated for chiropractors.

Wrap It Up

These symptoms of alleged toxin release after cervical spine manipulation may instead be an adverse event, a minor thromboembolic ischemic stroke caused by performing neck manipulation in the presence of an undiagnosed cervical artery dissection.  More education and clinical training in arterial dissection and stroke are recommended for chiropractors. Look, it’s complicated and I know Dr. Brown would agree with that statement.

There are no simple and easy answers. We are all at risk of having patients that are dangerous to adjust their cervical area with HVLA.  We know that Chaibi 2017 tells us that the main symptoms of danger are neck pain, headache, nausea, dizziness. Well hell. How many patients do we have that fit the neck pain and headache category? All day every day. 

I’ll put the research link at this point in the notes: https://www.tandfonline.com/doi/full/10.1080/07853890.2019.1590627?fbclid=IwAR3IYn5P5ppJsYymEpHEQe8AmOhNzH8xOfPJaswqNx3EQND-KiCxaXIK7LQ

But in Chaibi they say these are the key symptoms:

Well that’s a little more than a simple headache or neck pain, right? So that’s a little more clarity.  Jsut be educated. It’s not typically the older folks you’d think it is. It’s the young female that is usually vascularly compromised from hypermobility, EDS, connective tissue disorders.  Just a tip from your Ol’ Uncle Jeffro

Item #2 Our last one is called, “Metformin for Knee Osteoarthritis in Patients With Overweight or Obesity A Randomized Clinical Trial” by Pan et al and published in JAMA Network on April 24, 2025 and it’s all hotter a tin roof in Texas. 

Pan F, Wang Y, Lim YZ, et al. Metformin for Knee Osteoarthritis in Patients With Overweight or Obesity: A Randomized Clinical Trial. JAMA. Published online April 24, 2025. doi:10.1001/jama.2025.3471 https://jamanetwork.com/journals/jama/fullarticle/2833338?guestAccessKey=d11068e6-4d4d-48d2-ae41-e4c6dc1e0c2c&utm_source=silverchair&utm_medium=email&utm_campaign=jama_network&utm_content=network_highlights&utm_term=050425&adv=000003189471

So let’s start here: Traditionally, Metformin is used to treat high blood sugar levels that are caused by a type of diabetes mellitus or sugar diabetes called type 2 diabetes. So….it surprised me when I saw a paper having to do with metformin possibly being used in knee osteoarthritis. The math wasn’t mathing for me so it caught my eye and surprised me. So here we go. 

Why They Did It To evaluate the effects of metformin on knee pain at 6 months in participants with symptomatic knee osteoarthritis and overweight or obesity.

How They Did It Community-based randomized, parallel-group, double-blind, placebo-controlled clinical trial Individuals with knee pain for 6 months or longer, a pain score greater than 40 out of 100 on the visual analog scale (VAS), and body mass index of 25 or higher were recruited from the community through local and social media advertisements in Victoria, Australia, between June 16, 2021, and August 1, 2023. 

Interventions  Participants were randomly assigned to receive either oral metformin, 2000 mg/d (n = 54), or identical placebo (n = 53) for 6 months.

Main Outcomes and Measures  The primary outcome was change in knee pain, measured using a 100-mm VAS (score range, 0-100; 100 = worst; minimum clinically important difference = 15) at 6 months.

What They Found Of 225 participants assessed for eligibility, 107 (48%) were randomized and assigned to receive metformin or placebo.  Eighty-eight participants (82%) completed the trial.  At 6 months, the mean change in VAS pain was −31.3 in the metformin group and −18.9 mm in the placebo group, corresponding to an effect size (standardized mean difference) of 0.43.  The most common adverse events were diarrhea and abdominal discomfort.

Wrap It Up These results support use of metformin for treatment of symptomatic knee osteoarthritis in people with overweight or obesity. Because of the modest sample size, confirmation in a larger clinical trial is warranted. Alright, that’s it. Keep on keepin’ on. Keep changing our profession from your corner of the world. The world needs evidence-based, patient-centered practitioners driving the bus. The profession needs us in the ACA and involved in leadership of state associations. So quit griping about the profession if you’re doing nothing to make it better. Get active, get involved, and make it happen. Let’s get to the message. Same as it is every week. 

Store Remember the evidence-informed brochures and posters at chiropracticforward.com.   

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The Message

I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots. When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few. It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient. And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health!

Key Point: At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic!

Contact Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes.  Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms.  We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference. 

Connect We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

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About the Author & Host Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine (FIANM) and Board Certified Diplomate of the American Board of Forensic Professionals (DABFP) – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger    

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