The Microbiome & how Gut Health

can Influence the Musculo-Skeletal

System.
 About Me
• I studied Osteopathy at Victoria University, and graduated in 2000.
• Bachelor of Science (Clinical Science)
• Masters of Health Science (Osteopathy)
• I studied to be a Health Coach through IIN in 2015
• I started studying Naturopathy 3 times over the past 20 years before finally starting
and finishing my qualifications through AIAS, graduating in early 2018.
• Advanced Diploma of Naturopathy
• I also studied Nutritional Medicine through AIAS, graduating in early 2018.
• Advance Diploma of Nutritional Medicine
 Scope of Practice
OA - Statement of Scope of Practice in Osteopathy
JANUARY 2018
“Osteopathic healthcare includes a thorough primary care assessment and the
application of a range of manual therapies and health promotion strategies tailored to
the individual, that aim to optimise function and health” [1].

“Osteopaths use multiple clinical approaches including manual therapy, exercise advice
and prescription, lifestyle advice and education where appropriate”.

[1] Orrock, PJ. 2017. Developing an evidence base for osteopathic healthcare (PhD Thesis). Southern Cross University.
 Aims of this Webinar
• Give an overview of Gut Health, probiotics and prebiotics.
• Help Osteopaths feel more confident to offer advice to patients in terms of nutritional
advice, while still staying within scope of practice
• Help practitioners prescribe probiotics for common Musculo-skeletal conditions, in an
evidence based manner
• Help practitioners understand some common dietary lifestyle advice strategies for
common musculo-skeletal conditions
• Help practitioners know where to look for sound nutritional advice
• Help practitioners know where to look for and purchase supplements
• Help practitioners know where to look for, and how to offer appropriate testing to
patients.
Disclaimer
 The GIT
• Forms a 9 metre long ‘tube’ from
mouth to anus
• It’s surface area covers between 240-
400 m2
• About the size of a tennis court

Image: https://www.flickr.com/photos/nihgov/25083237542
 The Microbiome
• Can be considered an additional human organ
• This ‘microbe’ organ weighs 1-1.5kg
• The Human GIT microflora contains 1014 CFU/ml viable microorganisms
• This is 10x the number of cells in the human body
• From over 1000 different species

CFU = Colony Forming Units

 The Microbiome
• Stomach & Duodenum • Fusobacteria
• 101-103 CFU/ml • Enterobacteriaceae
• Lactobacilli • Clostridia
• Streptococci • Veilonella
• Yeasts • Lactobacilli
• Proteus
• Jejunum and ileum • Straphylococcus
• 104-108 CFU/ml • Pseudomonas
• Lactobacilli • Yeasts
• Enterobacteriaceae
• Streptococci
• Bacteroides
• Bifidobacteria
• Fusobacteria
• Colon
• 1010-1012 CFU/ml
• Bacteroides
• Bifidobacteria
• Stretococcoi
 The Microbiome
• The colonic microflora is believed to be the most important part of the GIT microflora.
• The bacterial concentrations here are greater than anywhere else in the GIT.
• Bacteria can be either:
• Potentially harmful
• Health promoting
Health benefits of the colonic microbiome.
• Modulate the immune system
• Enhanced GIT motility and function
• Improved digestion and nutrient absorption
• Production of vitamins
• Xenobiotic metabolism
• Colonisation resistance
• Production of SCFAs
• Production of polyamines
• Weight management
 Eubiosis
The normal state of affairs in the health GIT.

Dysbiosis
Qualitative and quantitative changes in the intestinal flora, their metabolic activity or
their local distribution that produces harmful effects on the host.

Modern diet and lifestyle, as well as the use of pharmaceutical drugs, has lead to the
disruption of the normal intestinal microflora and/or its activities [2].

[2] Hawrelak & Myers, 2004

 Dysbiosis
Dysbiosis is believed to play a part in many chronic and degenerative diseases.

Two types:
• Small intestinal dysbiosis
• Small intestinal bacterial overgrowth (SIBO)
• Colonic dysbiosis

[2] Hawrelak & Myers, 2004

 Causes of Dysbiosis
• Antibiotics
• Chemotherapy
• Stress
• C-section delivery
• Birth location
• Formula feeding
• Diet
• Sulphates & Sulphites (preservatives)
• High protein diet
• Diet high in animal protein
• Diet high in fat
• Diet high in milk fat
• Diet high in refined carbohydrates
• Artificial Sweeteners
Examples: Dysbiosis &
the MSK system.
Rheumatoid Arthritis
Rheumatoid Arthritis
Obesity
Obesity
Adhesive Capsulitis
How does dysbiosis
influence the MSK
system?
 Dysbiosis

Intestinal Hyperpermeability (Leaky Gut)

Systemic inflammation

In treating musculo-skeletal conditions we
need to address systemic inflammation
also
Intestinal Hyperpermeability (Leaky Gut)
• What is it?
• How does it come about?
• What can it lead to?
• What to do about it:
• Reduce stress
• Reduce toxic load
• Improve diet
• Eliminate any dietary irritants
• Address any parasites, yeast
overgrowth and/or bacterial
imbalances
• Improve any bacterial dysbiosis
 Intestinal Hyperpermeability
• Reduce stress
• Reduce toxic load
• Improve diet
• Eliminate any dietary irritants
• Address any parasites, yeast overgrowth and/or bacterial imbalances
• Improve any bacterial dysbiosis
 Reduce Stress
• Exercise
• Meditation
• Yoga
• Breathing exercises
• Relaxation techniques
• Float therapy
• Massage
• Osteopathy treatment
• Cranial Osteopathy
• Counseling / Psychology
 Intestinal Hyperpermeability
• Reduce stress

• Reduce toxic load

• Improve diet
• Eliminate any dietary irritants
• Address any parasites, yeast overgrowth and/or bacterial imbalances
• Improve any bacterial dysbiosis
 Reduce Toxic Load
• Reduce use of:
• Plastic food storage
• Plastic water bottles
• Make-up/hair/beauty products with chemicals
• Cleaning products with chemicals
• Pesticides
• Fragrant candles (non-organic)
• Perfumes (non-organic)
• Nail polish (non-organic)
• Sunscreens (non-organic)
• Spray tans / fake tans (non-organic)

• Reduce intake of:

• Preservatives
• Colourings
• Additives
• Trans fats

• My favourite online shopping website: www.nourishedlife.com.au

 Intestinal Hyperpermeability
• Reduce stress
• Reduce toxic load

• Improve diet
• Eliminate any dietary irritants
• Address any parasites, yeast overgrowth and/or bacterial imbalances
• Improve any bacterial dysbiosis
 Improve Diet
• Eat fruits and vegetables from all colours of the rainbow, aim for organic
• Eat more greens
• Eat more good fats, less bad fats
• Drink more water
• Eat less processed foods
• Eat less processed sugars
• Drink less alcohol
• If eating meat, not too much, and aim for organic / grass fed

Eat Real Food, Not Too Much, Mostly Plants

 Intestinal Hyperpermeability
• Reduce stress
• Reduce toxic load
• Improve diet

• Eliminate any dietary irritants

• Address any parasites, yeast overgrowth and/or bacterial imbalances
• Improve any bacterial dysbiosis
 Eliminate any dietary irritants
• The patient could eliminate one or more of the 3 main common culprits:
• Gluten
• Dairy
• Sugar
• Or they could eliminate any allergens that they think may be specific to them

• The only way to know for sure is to do an elimination diet.

• This is complex and can take months.
• IgG and IgA food intolerance testing is common among alternative health practitioners as an easier
option than an elimination diet. I’ll let you know soon why I’m not keen on them.
 Eliminate any dietary irritants
• Elimination Diet
• The patient will need to eliminate all common reactive foods:
• Wheat
• Soy
• Eggs
• Chocolate
• Coffee
• Refined sugars
• Citrus
• Dairy
• Butter
• Cheese
• Milk
• Ice-cream
• Cream
• If any of these foods are causing an irritation to the patient, they will notice an improvement in
symptoms within 7-10 days.
 Eliminate any dietary irritants
• They need to stay on this elimination diet for 1 month.
• After this, the patient will challenge different foods by adding them 1 by 1 back into the diet.
• They can add their favourite food first and have lots of it over 1-2 days.
• They need to be observant of any symptoms appearing.
• They then need to stop eating that food, and wait 3-4 days after all symptoms have settled before
repeating the process with the next food to see how that then responds in the body.
• If no symptoms seem to appear, wait 3-4 days after the 1-2 days of eating that food, before adding the
next food in.
• Foods need to be separated, ie for eggs, you would add back in whites separately to yolks.
• You would separate dairy, and test cream, butter, milk, cheese, yoghurt, ice-cream separately
• You would advise the patient to keep a food diary around symptoms
• The challenge takes 3-4 months to work out the worst irritants.
• Once the elimination/challenge is finished, you would advise the patient to stay off all irritating
foods for 6-12 months, and then only eat once every 3-4 days, so that if they do eat it, and it causes
a reaction, their body has time to settle again before eating it and reacting again.
 Eliminate any dietary irritants
• Food intolerance testing
• Nutripath – igA and igG
• IgA and IgG reactions are known as delayed response reactions, that include food sensitivities, where IgE
responses are immediate and are considered a true food allergy. IgA and IgG reactions may not happen
immediately, but can take hours or days to show us, causing symptoms related to inflammation like
headaches, fatigue, brain fog or joint pain.
• While you can test for IgG and IgA for food reaction, this is not diagnostic of hypersensitivity or allergy,
but sensitivity and intolerance, as well as inflammation. These tests are controversial as the results are
commonly not reproducible and are not as reliable as elimination diets for working out food sensitivities.
• You might consider IgG and IgA testing if an elimination diet may be too difficult or time consuming for
the patient to undertake.
• I don’t ever do them with my patients as if the results are not reproducible, then they are not accurate
enough for me.
 Intestinal Hyperpermeability
• Reduce stress
• Reduce toxic load
• Improve diet
• Eliminate any dietary irritants

• Address any parasites, yeast overgrowth and/or

bacterial imbalances
• Improve any bacterial dysbiosis
Address any parasites, yeast overgrowth
and/or bacterial imbalances
Stool testing:

• Nutripath: CDSA2 – takes about 3 weeks

• Doctors Data – Comprehensive Stool Analysis +/- Parasitology $419 - $499 – from rnlabs.com.au –
takes 6-7 weeks.
• uBiome – American company - Takes 6-7 weeks. $99
• Microba – Australian company – Takes about 4 weeks $349
 Intestinal Hyperpermeability
• Reduce stress
• Reduce toxic load
• Improve diet
• Eliminate any dietary irritants
• Address any parasites, yeast overgrowth and/or bacterial imbalances

• Improve any bacterial dysbiosis

 Improve any bacterial dysbiosis
• Probiotics
• Definition: Live microorganisms which when administered in adequate amounts confer a health benefit
on the host
• Includes:
• Specific supplements containing freeze-dried bacteria
• Fermented foods such as yoghurt, sauerkraut, kimchi and kefir
• Prebiotics
• Definition: a nondigestible food ingredient that beneficially affects the host by selectively stimulating the
growth and/or activity of one or a limited number of bacteria in the colon.
 Probiotics
Why do you choose a certain probiotic?

• Brand loyalty
• Glossy brochure / educational material
• Rep brings you lunch
• Mega high CFU counts (CFU = Colony Forming Units)
• Multiple species
• Strain Specificity
 Probiotics
Characteristics of bacteria (actions and qualities) are strain specific, ie strains of bacteria
within the same species may vary in regards to:
• Shelf stability
• Resistance to gastric acids and bile salts
• Adherence capacity and method of adherence to the intestinal mucosa
• Colonisation capacity
• Ability to produce anti-microbial compounds
• Clinical efficacy
Strain Specificity Probiotics
What is a strain?
Bacterial naming system:

Lactobacillus acidophilus LA5

Genus Species Strain

• You cannot extrapolate research conducted on one strain to another – even if they are
within the same species.
• Concept of strain specificity has only become known in the last 20 years.
• Some supplement companies are aware of this but choose to ignore it, and therefore
rely on practitioner ignorance to sell their supplements.
 Probiotics
The most important part of prescribing probiotics is choosing the right strain for the job.

The Probiotic Advisor – Dr Jason Hawrelak

Annual Subscription $49

Conditions Index
• Quality of evidence – star rating
• Summary of results of evidence for a whole list of conditions
• Where the strain is found in food sources and in supplements, relevant to Australia,
Canada and USA.
 Probiotics
How do they work?

• Compete with potentially pathogenic bacteria and fungi along the GIT for the limited space that is
available.
• Car Park Theory: If more parks are taken by commensal bacteria, it is less likely that pathogenic bacteria or fungi can
park there also.
• Antagonism against potentially pathogenic microorganisms
• Interact with immune cells
• Produce beneficial compounds in the gut
• SCFA’s
• Polyamines
• Anti-inflammatory activity
• Modify GIT Transit
• Decrease visceral hypersensitivity
• Strengthen the intestinal barrier
 Probiotics
Dosage

• Minimum effective dosage appears to differ by strain.

• Best practice is to ensure the supplement contains bacteria in concentrations ≥ 109
CFU/dose (unless research shows otherwise).
• If a formula contains multiple strains, each strain must be present in amounts ≥ 109

Advise patients to take each dose 1-2 x per day

 Evidence Based Probiotic Prescription
Rheumatoid Arthritis

Food sources: Mojo Kombucha

Supplement sources: Nature’s Way AU Daily Probiotic Vita Gummies
 Evidence Based Probiotic Prescription
Migraine

Supplement sources: Mediherb

Probiotica Clinical
 Evidence Based Probiotic Prescription
Bone Fracture – for enhance recovery

Food sources: Yakult, Yakult Light

Supplement sources: None in Australia atm
 Evidence Based Probiotic Prescription
Following NSAID use

Food sources: Parmalat Vaalia

Supplement sources: LOTS! The ones I use are: Metagenics Ultra Flora LGG, Metagenics Ultra Flora Restore,
Metagenics Ultra Flora Immune Control, Metagenics Ultra Flora Immune Enhance, Metagenics Ultra Flora
Mother & Baby.
 Evidence Based Probiotic Prescription
Otitis Media - Prevention

Food sources: Parmalat Vaalia

Supplement sources: Solgar Advanced Multi-Billion Dophilus, Caruso’s Natural Health Alive Probiotic, Metagenics Ultra
Flora Intensive Care AU, Megagenics Ultra Flora Mother & Baby.
 Evidence Based Probiotic Prescription
Physical Performance – Exercise recovery

Food sources: Mojo Kombucha

Supplement sources: Nature’s Way AU Daily Probiotic Vita Gummies
 Evidence Based Probiotic Prescription
Weight Management

Supplement sources: Metagenics Ultra Flora Control, Metagenics Ultra Flora MetaControl
 Prebiotics
Most commonly available
• FOS – Fructooligosaccharides
• Garlic, onions, jerusalem artichokes, chicory root, dandylion leaves, yacon root
• Targeted microbes: Bifidobacteria
• Lactulose
• UHT milk
• Targeted microbes: Lactobacilli & Bifidobacteria
• GOS – Galactooligosaccharides
• Human milk, Cow’s milk
• Targeted microbes: Lactobacilli & Bifidobacteria
• Supplements: Bimuno Daily
• PHGG – Partially Hydrolysed Guar Gum
• Supplements: Biomedica Laxpro
 Prebiotics - FOS
Uses of FOS

• Dsybiosis
• Enhancement of immunity
• Enhanced absorption of calcium in osteoporosis and osteopenia
• Via a decrease in colonic pH which results in increased solubility of calcium, increased colonic venous blood flow,
enlarged colonic villi, enhanced expression of calbindin-D9K (the active calcium transport route).
• Damaged intestinal or colonic musoca
• Promotion of satiety

Dosage
• 10g day
• Start with a lower dose first and build up because can cause bloating and wind.
 Prebiotics - GOS
Uses of GOS

• Dsybiosis
• Constipation
• Increased resistance to infections
• In the treatment of IBS
• Improved absorption of calcium
• Metabolic Syndrome – decreasing systemic inflammation
• Prevention of GIT infections
• Prevention of travellor’s diarrhoea

Dosage
• 2.5-15g/day. Mostly don’t need to go over 5g/day
• Start with a lower dose first and build up
 Prebiotics - Lactulose
Uses of Lactulose

• Dsybiosis
• Candidiasis
• Constipation
• Damaged intestinalor colonic musoca
• Alcoholic fatty liver disease
• Lowered immunity
• Prevention of UTI’s

Dosage
• 10g 2 x day (in constipation dose is 15-40g/day, in liver disease is 35g/day)
• Start with a lower dose first and build up because can cause bloating, diarrhoea, abdominal pain and
wind.
 Prebiotics – PHGG
Uses of PHGG – Partially Hydrolysed Guar Gum

• Dsybiosis
• Constipation
• IBS
• SIBO

Dosage
• 5 g / day
 G.E.R.D / Reflux / Indigestion
What we, as Osteopaths, can do
• Visceral manipulation techniques on the stomach
• Medial / lateral glide technique
• Vertical motion technique
• VM1 – www.barralinstitute.com.au
• Brisbane – Early April 2019
• Adelaide – early Oct 2019
• Structural techniques on diaphragm, cervical region and thorax
• Offer advice:
• Eat smaller portions
• Chew food really well
• Don’t eat too much at night
• Avoid rich, spicy or fatty foods
• Refer to a Naturopath as they can offer great support with herbal medicines and support patients
to come off PPI’s over a period of 6-12months.
 IBS
What we, as Osteopaths, can do
• Visceral manipulation techniques on the small and large intestines
• VM1 – www.barralinstitute.com.au
• Brisbane – Early April 2019
• Adelaide – early Oct 2019
• Structural techniques on lumbar and pelvic regions
• Offer advice:
• Food elimination diets
• Avoid known or common food sensitivities like gluten, dairy, citrus, soy and refined sugars.
• Correct nutritional deficiencies in B Vitamins, Zinc, Vit A, Vit C, Vit D
• Avoid eating too many different types of foods at the one time
• Stick to one type of starch at each meal
• Eat foods slowly, chew well, and eat in a calm atmosphere
• Eat more steamed vegetables than raw ones
• FODMAP diets – only a short term treatment, patients shouldn’t be on long term
 SIBO
What we, as Osteopaths, can do
• Visceral manipulation techniques on the sphincters - IVC
• VM1 – www.barralinstitute.com.au
• Brisbane – Early April 2019
• Adelaide – early Oct 2019
• Structural techniques on lumbar and pelvic regions
• Refer for breath testing or to a Naturopath for specific treatment
• Offer advice:
• Have breaks of greater than 90 minutes between eating to allow time for the Migratory Motor Complex to work.
• Food elimination diets
• Avoid known or common food sensitivities like gluten, dairy, citrus, soy and refined sugars.
• Correct nutritional deficiencies in B Vitamins, Zinc, Vit A, Vit C, Vit D
• Avoid eating too many different types of foods at the one time
• Stick to one type of starch at each meal
• Eat foods slowly, chew well, and eat in a calm atmosphere
• Eat more steamed vegetables than raw ones
• FODMAP diets – only a short term treatment, patients shouldn’t be on long term
 Special Diets
Diet for Intestinal Dysbiosis
• Increase:
• Green vegetables
• High-fibre diet
• Bitter foods: artichoke, ginger, broccoli, radicchio, rocket, brussel sprouts, chicory, asparagus, endive,
kale, grapefruit, chocolate (90-100%), dandelion, eggplant
• Reduce:
• Meat
• Sugar and sweet foods
• Spicy foods
• Fried foods
• Fatty and rich foods
• Salty foods
• Alcohol
• Caffeine
• Coffee
 Special Diets
Diet for Leaky Gut
• Zinc helps to strengthen the tight junctions and therefore improve barrier function of intestinal
epithelial layers.
• Foods rich in Zinc:
• Oysters
• Meat
• Eggs
• Seafood
• Black-eyed peas
• Tofu
• Whole grains
• Wheat germ
• Supplements:
• Zinc Citrate
• Zinc Picolinate
 Special Diets
Diet for Leaky Gut
• Glutamine enhances intestinal absorption of nutrients & decreases intestinal permeability. Needs
to be at high doses of 20g/day for it to work.
• Foods rich in Glutamine:
• Bone broth
• Grass fed whey protein
• Grass fed raw dairy
• Grass fed beef
• Spirulina
• Cabbage
• Asparagus
• Broccoli
• Venison
• Organic poultry
• Supplements:
• Metagenics – Glutagenics + many others
 Special Diets
The Anti-inflammatory Diet
 Special Diets
The Anti-inflammatory Diet
 Special Diets
The Anti-inflammatory Diet
 Special Diets
The Auto-Immune Diet
 Special Diets
The Auto-Immune Diet
 My Favourite Resources
for nutritional information and advice
• Probiotic Advisor
• For evidence based prescription of probiotics
• Pubmed
• Clinical Key
• Mytavin
• An online tool where you can check what medications a patient is on, and what evidence based
nutritional deficiencies/symptoms may be a result of being on that medication.
• Health Masters Live
• Offer Online Masterclasses in Natural Medicine in all sorts of areas.
• Dr Jason Hawrelak – The Natural Gastrointestinal Masterclasses 1 & 2
• nPod
• Online tool to find what supplements contain what ingredients, and compare with others
 Supplement Companies
and some of my favourite supplements for gut health
• Integria
• Mediherb - P2Detox
• Oborne
• Metagenics
• A great range of probiotics
• Glutagenics
• MetaPure EPA/DHA
• Biomedica
• Laxpro
• Biomatrix
• PeptEase
• BicoZn
• Enterocare
• Bioceuticals
• UB75
• Mediherb
• P2Detox
• Nutrition Care (order from Oborne)
• Polybac
 Testing Companies
• Nutripath
• Australian Clinical Labs
• Research Nutrition (RNLabs)
 Naturopathic & Nutritional Support
I do offer online (Skype or Zoom) and phone consultations for Naturopathy and Nutrition
if you would ever like any additional support for your patients.

Andrea Robertson
Southside Clinic
1 Hughes St, Unley SA 5061
Phone: 1300 10 11 22
Web: southsideclinic.com.au
Email: [email protected]
Instagram: @dr_andrearobertson