Sunday, March 7, 2021

No Need To Stretch Or Foam Roll Your ITB?


You are a runner and you haven't been able to run more than 2 km before a sharp pain in your outer knee reduces your run to a hobble. Resting, icing and changing your running shoes made no difference. The sports doctor you saw just diagnosed you with the dreaded Iliotibial Band Syndrome (ITBS). He tells you that you need to stretch your Iliotibial band (ITB) and use a foam roller.

Sounds familiar? Well, this latest published paper on the ITB by Paul Giesler (2020) challenges common treatment approaches of stretching and massaging the ITB. Basically, he says that you do not want to stretch or foam roll your ITB.

I've written about the ITB before in a few different posts. Except for Daniel Liberman and Carolyn Eng's study, most other articles seem to suggest that the ITB causes pain via a 'friction syndrome'. This is thought to be due to the ITB rubbing to and fro over Gerdy's tubercle on the outer shin bone while running due to hip weakness. 

Treatment is normally targeted at stretching the ITB (to reduce friction). Doctors will often suggest a steroid injection to reduce 'inflammation' (in the bursa) on the outer knee.  Giesler (2020) however,  suggested that ITB pathology is more likely to involve compression of sensitive structures beneath the ITB rather than friction.

also know as Iliotibial tract (ITT)

Since the ITB is a really broad, strong and complex structure with many attachments (picture above) along the hip, thigh and around the knee, it can provide stability for both the hip and knee. Like I wrote before, the ITB is actually thought to function like our Achilles tendon. To store and release energy like a spring. Therefore you cannot and would not want to stretch a spring. A coiled spring can release energy much better than a spring that is stretched out.

From Carolyn Eng's running simulation 

Hence the need to treat the cause of the problem rather than just treating the pain over the outer knee. Hip strength and control thus thought to be key in causing ITBS, especially weakness in hip increased hip adduction (dropping of the hip inwards) during loading. 

Runner on L has increased hip adduction

In runners/ patients with excessive hip adduction while running, progressive rehab and addressing potential causes should be adapted for individual runners, especially while running downhill and during longer runs. I've written on this topic specifically, you can read that article here.

So treatment should be to calm the symptoms (knee pain) and treat the cause. We don't get you to stretch your ITB or use the foam roller in our clinics, come see us if you want to run pain free.

The Paul Geisler (2020) article is free, click on the link under references if you want to read it.


References

Bramah C, Preece SJ Nimh G et al (2018). Is There A Pathological Gait Associated With Common Soft Tissue Running Injuries? AJSM. 46(12): 3023-3031. DOI: 10.1177/0363546518793657

Eng CM, Arnold AS, Liberman DE et al (2015). The Capacity Of The Human Iliotibal Band To Store Elastic Energy During Running. J Biomech. pii: S0021-9290 (15) 00354-1. DOI:10.1016/j.jbiomech.2015.06.017.

Geisler PR (2020). Iliotibial Band Pathology: Synthesizing The Available Evidence For Clinical Progress. J Ath Trg. DOI: 10.4085/JAT0548-19

Sunday, February 28, 2021

Shoulder Still Painful After Subacromial Decompression Surgery

Recently, we had a patient referred to our clinic for his shoulder pain (shoulder impingement). He had pain just lifting his arm/shoulder sideways. After talking to him, he mentioned that he already had surgery a few years ago to remove part of his acromion to increase the subacromial space. 

R shoulder impingement

This surgery (usually called subacromial decompression) is done to free up more space for the supraspinatus muscle and subacromial bursa so there is less chance of an impingement.


If part of the acromion (see picture above) was already shaved off and removed, how can the patient still be getting shoulder pain from shoulder impingement?

Actually, I was not surprised at all. Two recent systematic reviews/ meta-analyses and a Cochrane systematic review (referenced below) concluded with high certainty that for patients who painful shoulder impingement, subacromial decompression surgery does not help. Pain wise, function or health-related quality of life is not better compared with placebo surgery or physiotherapy.

In the United States alone, there are more than 500,000 procedures of subacromial compression done for subacromial pain, or in conjunction with a rotator cuff repair every year. 

In another recently published study, authors from Finland did a 5 year follow up on patients to compare arthroscopic subacromial decompression versus diagnostic arthroscopy, a placebo surgical intervention, and exercise therapy. They found that arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy or exercise therapy at 5 years follow up.

Looking at all the current evidence, if you have subacromial shoulder pain or shoulder impingement, then it is safe to say that going under the surgeon's knife may not help after all. The study by Paavola et al (2020) suggested exercise therapy was just as effective.

What did we do? Treating his neck and nerve root irritation got rid of his shoulder pain.

References

Hao Q, Devji T, Zeraatkar D et al (2019). Minimal Important Differences For Improvement In Shoulder ConditionPatient-reported Outcomes: A Systematic Review To Inform a BMJ Rapid Recommendation. BMJ Open DOI: 10.1136/bmjopen-2018-028777.

Karjalainen TV, Jain NB, Page CM et al (2019). Subacromial Decompression Surgery For Rotator Cuff Disease. Cochrane Database Syst Rev. 1:CD005619. DOI: 10.1002/14651858.CD005619.pub

Lahdeoja T, Karjalainen TV, Jokihaara J et al (2020). Subacromial Decompression Surgery For Adults With Shoulder Pain: A Systematic Review With Meta-analysis. BJSM. 54: 665-73. DOI: 10.1136/bjsports-2018-10048.

Paavola M, Kanto K, Ranstam J et al (2020). Subacomial Decompression Versus Diagnostic Arthroscopy For Shoulder Impingement: A 5-year Follow-up Of A Randomised, Placebo Surgery Controlled Clinical Trial. BJSM 55(2): 99-107. DOI: 10.1136/bjsports-2020-102216.

Sunday, February 21, 2021

Many Physiotherapists Cannot Prescribe Exercise?


Teaching Ronald Susilo how to ride

I definitely don't agree with the following research (Barton et al, 2021) which concluded that physiotherapists cannot prescribe physical activity and exercise well for people with muscle and joint pain/ problems. Let me explain further.

I was asked to go to court last year to be questioned by the lawyer of the insurer (for the truck driver) for my accident in 2013. Yes, after waiting for almost 7 years, and numerous adjournments by the other party, the hearing was finally scheduled. 

Their lawyer questioned why I needed physiotherapy after my accident and he added that "isn't physiotherapy just doing some exercises". If so then I would not need to attend any more sessions and just do the exercises at home and the insurer would not have to pay anymore.

I explained that he (and perhaps the general public) may think when you see a physiotherapist, all the physiotherapist does is to teach you strengthening exercises for your pain or condition. But teaching strengthening exercises isn't the only thing physiotherapists do. At least not at our clinics anyway. 

But physiotherapists in Singapore can definitely teach exercises, especially in the hospital setting. That's what my patients tell me anyway.

Back to the study. 1,352 physiotherapists from 56 countries were surveyed. Most agreed that their job requires exercise prescription of aerobic exercise (75%) and resistancestrength training (89%) to patients with muscle and joint pain/ problems. 

38 to 50 percent of the physiotherapists reported that they were not confident and had no training/ skills to prescribe aerobic exercise and resistancestrength training (50 to 67%). Only 11% were able to give the correct guidelines for aerobic exercise and resistancestrength training (21%).

62 to 79 percent  felt that their packed schedule (seeing too many patients), access to equipment/ space and lack of opportunity to attend professional development affected their ability to prescribe guidelines for effective exercise. 

The authors concluded that many physiotherapists lack training and knowledge to give advice for physical activity, and to prescribe resistancestrength training and aerobic exercise to people with muscle and joint pain.

The general public (and the lawyer that quizzed me) thinks that all a physiotherapist does is teach exercise for treatment. Is that what you think?

Reference

Barton CJ, King MG, Dascombe G et al (2021). Many Physiotherapists Lack Preparedness To Prescribe Physical Activity and Exercise To People With Musculoskeletal Pain: A Multi-national Survey. Phy Therapy in Sport. DOI: 10.16/j.ptsp.2021.02.002.

Saturday, February 13, 2021

Cupping Gone Bad

Picture from Newsflash/ Australscope

Cupping became very popular after Michael Phelps was pictured with cupping marks on his back while competing at the 2016 Rio Olympics.

However, there was a major outcry after a three month old baby with 'too much gas' in Turkey was pictured being treated by cupping. At least cupping seems better compared to a two week old baby being treated by a chiropractor in Melbourne.

In my humble opinion, treatments like that should not be allowed when a child is that young.

Research (a meta-analysis of 135 controlled trials) show that there seems to be no negative effects on adults if cupping was done in moderation (Cao et al, 2012) In addition, adults are able give consent and feedback.

Picture from CEN/ Australscope

Treatment can go wrong with adults too. The 63 year old man pictured above wanted to treat his 'frozen shoulder' and went for cupping treatment 10 days in a row. The person treating him placed the cups in exactly the same positions daily. He was due to continue with the same treatment for two more days but experienced severe pain and a high fever. Fortunately, he went to the hospital instead. 

The following article explains how cupping for treatment works and attempts to offer possible  explanations of its effects (Al-Bedah et al, 2019), of which includes the Pain Gate Theory, TENs, blood detoxification and Reflex zone theory etc. However, no single theory exists to explain the whole effect of cupping.

Well, what we can learn from the above incidences is to ensure that cupping isn't done to the same spot on consecutive days.

References

Al-Bedah AMN, Elsubai IS, Qureshi NA et al (2019). The Medical Perspective Of Cupping Therapy: Effects And Mechanisms Of Action. J Tradit Complement Med. 9(2): 90-97. DOI: 10.1016/j.jcme.2018.03.003

H Cao, X Li and J Liu (2012). An Updated Review Of The Efficacy Of Cupping Therapy. PLos One. 7(2): e31793. DOI: 10.1371/journal.pone.0031793.

Sunday, February 7, 2021

Motion Control Shoes To Control Overpronation?

Brooks Adrenaline GTS 21
Most of our patients choose their running shoes based on comfort. Recently, we've had a few new patients who were told to buy motion control shoes to control pronation. Yes, there are still sales people from running shoe shops, doctors, physiotherapists and podiatrists etc who recommend running shoes based on their foot type

They will check if you have a normal, high, low/ or no arches and then recommend you use stability, cushion and motion control shoes respectively. The rationale for motion control shoes are that since a person with low or no arches tends to overpronate, they need sturdy motion control shoes to control that overpronation.

What does current research say?

327 runners were studied and followed up for six months by researchers. The runners were randomly allocated to run in neutral running shoes or motion control shoes (Malisoux et al, 2016). The researchers concluded that runners who used motion control shoes will benefit those with low/ no arches (or or pronated feet).

Another group of researchers (Willems et al, 2020) reanalyzed data from Malisoux's 2016 study to include type of injury sustained. Malisoux was also in this current group of researchers. Running injuries that occurred were classified into pronation related (Achilles tendinopathy, plantar fasciitis, exercise related lower leg pain and anterior knee pain) or other running related injuries.

Upon analysis, 25 runners were found to have sustained pronation related injuries while 68 other runners had other running related injuries. Those who ran with a motion control shoe had a lower risk or pronation related injuries while there was no difference on the risk of other running related injuries.

The above mentioned results differs from previous published research on motion control shoes which showed that runners who overpronated and assigned to run in motion control shoes actually complained of pain and missed training days after wearing them (Ryan et al 2011). Another published study involving 927 new runners also found that pronation is not associated with increased injury risk.

The contrast in conclusions will no doubt confuse you. I was initially confused too. It is always difficult to combine multiple sources and research methods to come away with practical results because the definitions vary.

The main question for me in the Willems et al (2020) study is how do they really know any of the running injuries are 'pronation related'? They also defined injury as pain interfering with training for 1 day. Other studies defined injury as no running for a week.

My suggestion is to assess individual response to change in footwear and see if it reduces pain/ injury. If it does, then you should lay off that pair of running shoes for a while before trying it again. 


References

Nielsen RO, Buist I, Parner ET et al (2014). Foot Pronation Is Not Associated With Increased Injury Risk In Novice Runners Wearing A Neutral Shoe: A 1-year Prospective Cohort Study. BJSM. 48: 440-447. DOI: 10.1136/bjsports-2013-092202

Malisoux L Chambon N, Delattre N (2016). Injury Risk In Runners Using Standard Or Motion Control Shoes: A randomised Controlled Trial With Participant And Assessor Blinding. BJSM. 50(8): 481-487. DOI: 10.1136/bjsports-2015-095031

Ryan MB, Valiant GA, McDonald K et al (2011). The Effect Of Footwear Stability Levels On Pain Outcomes In Women Runners: A Randomised Control Trial. BJSM. 45:715-721. DOI:10.1136/bjsm.2009.069849 

Willems T, Ley C, Goetghebeur E et al (2020). Motion Control Shoes Reduce The Risk Of Pronation-related Pathologies In Recreational Runners: A Secondary Analysis Of A Randomized Controlled Trial. JOSPT. pp 1-31. DOI: 10.25

rent Malisoux,
1
Nicolas Chambon,
2
Nicolas Delattre,
2
Nils Guegu

Sunday, January 31, 2021

Oakley Sutro Review


I got a nice surprise earlier this week from Oakley Singapore- the Sutro sunglasses in red. They were actually released earlier a while ago but I only just got mine. Better late than never.

I tried it during my bike ride yesterday and it was awesome.

My fellow cycling friends who bought the Sutro's earlier said the long ear stems did not sit well with their helmets' adjusting and fastening. I use the Giro Air Attack helmet and they were fine.


Another comment was since the ear stems did not have any rubber (Oakley uses Unobtanium) to hold the sunglasses in place, they are not as secure and tends to move around. Again, they felt fine on my face while on the bike. Perhaps if you're riding off road or running they may be less secure with all the movement. However, I really like the retro Oakley wording (pictured above) on my ear stems compared to the 'O' Oakley logo commonly used now.

Greg Lemond and the Factory Pilots

I found out that the Sutro is modeled after the Oakley Factory Pilot Eyeshades made popular by Greg Lemond In the 1980's. Lemond won the Tour De France in 1985 wearing the Factory Pilot's and and they were the sunglasses many cyclists wore back then. There is a nice tribute to the Factory Pilot just above the nose piece (picture below).

Nice tribute

The huge, goggle style lens may not suit everyone's taste, but I think they're great at providing a large field of vision. The holes provide more than ample ventilation and they definitely didn't fogged up during yesterday's ride. Peripheral vision is superb with the Sutro's and you would expect nothing less in any Oakley sunglasses. Definitely a plus for cyclists.

Thanks again to Joey from Oakley Singapore.


*I remember watching Greg Lemond (above) winning the 1989 Tour De France by 8 small seconds over Laurent Fignon on the final day in the individual time trial (ITT). He had a deficit of 50 seconds before the day started. No one thought Lemond could pull it off as the ITT was just 25 km long. You can't make up 50 seconds over 25 km. But Lemond did, he averaged 54.545km/h in what was then the fastest ITT ever! 

The race was the greatest ever comeback in modern history as Lemond was shot by accident by his brother in law when they were hunting in April 1987 (Lemond first won the TDF in 1985 and 'gifted' the race to teammate Bernard Hinault). He underwent two surgeries and missed the TDF in 1987 and 1988.

Wednesday, January 27, 2021

Run On Softer Surfaces Or Improve Running Technique?


I read with interest two recent letters written to the Forum page in the Straits Times in the past month. One writer suggested making softer surfaces for runners at park connector paths to take care of runners' knees.

Another writer said it's not the running surface but a runner's poor running technique that causes the knee joints to wear out.

In today's Forum page, another two writers wrote in with their comments. The first writer acknowledged that both running surfaces and running technique may be the cause of knee problems. However, he thinks that excess weight may be a contributing factor too since 30 percent of 500 respondents in a survey said they had gained 5kg during the pandemic (of course there were many others who lost weight too).

The second writer, a medical doctor suggested brisk walking rather than running for joint longevity. He also said that his heathiest octogenarian patients maintain a healthy weight by being active through walking rather than pursuing 'exercise achievement goals'.

Running definitely does not wear out your knees. I've written about this before and there is so much research supporting this.

If anyone should be paranoid about running wearing out the knee joints, it should be me after 3 knee operations. The following are my personal views, backed by published articles. 

Although research has shown that there is no difference between running on the road versus grass in terms of leg inflammation, I personally feel it is much softer to run on grass or the soft sand on the beach compared to running on the pavement or road.

If you're heavier, that can put more load on the joints definitely, but running does not wear out the joints. By all means improve your running technique or do deep water running if you have to.

Be patientincrease your training load gradually, have at least one rest day a week and don't do too much too soon.

*Have a look at page A17 in today's Straits Times (270121)

Sunday, January 24, 2021

How To Increase Range Of Motion

All the kids posed for this picture

A typical comment from many of our patients is that they have been stretching all the time but their muscles still feel tight. 

Range of motion (ROM) is necessary as part of our health and important during sports performance. And static stretching is often prescribed to get better ROM gains. We know from previous research that static stretching is effective in improving our range of motion. 

However, the latest systematic review/ meta-analysis shows that strength training (ST) is just as effective as static stretching in getting improvements in ROM.

The researchers pooled data together and found eleven good quality studies comprising 452 participants to derive the following results.

Interventions lasted between 5 and 16 weeks while training frequency ranged from two to five times a week. Subjects included healthy sedentary subjects, subjects who already participate in ST subjects with fibromyalgia and subjects with chronic neck pain. There were also elderly adults who had difficulties in one of four tasks, transferring, bathing, walking and going to the toilet.

Both ST and static stretching groups showed significant improvement in ROM in seven of the studies. Differences between the groups were non significant. They did not find any significant differences in active and passive ROM for both ST and stretching. Dynamic stretching did not improve ROM in any of the groups.

You must be wondering how ST helps to improve ROM that is not statistically distinguishable from static stretching. The authors wrote that ST with an eccentric focus requires the muscles to produce forces in a lengthened position. This is what helps improve ROM. They also found that concentric strength training improves ROM when full range is required.

One study demonstrated significant reductions in pain associated with increases with strength, suggesting that decreased pain sensitivity may be another mechanism in which ST help increase ROM. Another mechanism may be an improved agonist-antagonist co-activation helping ROM gains.

The authors concluded that both ST and static stretching can improve ROM both in the short and long term suggesting that there are both neural and mechanical factors at work. Both ST and stretching can be prescribed to help improve ROM. If one does not respond or adhere well to a stretching program, they can switch to strength training instead.

What does that all mean you (if you did not understand the discussion above)? If you're looking to get an increase in your range of motion say in your knee joint, you can do eccentric strengthening exercises with some stairs at home. This previous article explains everything in a simple manner.

Just remember that static stretches are best done after exercise as just one bout of static stretching can slow you down as well as reduce your maximum strength.


Reference

Afonso J, Ramirez-Campillo R, Moscao J et al (2021). Strength Training Is As Effective As Stretching For Improving Range Of Motion: A Systematic Review And Meta-analysis. DOI: 10.31222.osf.io/2tdfm

Sunday, January 17, 2021

Is Good Posture Just A Myth?


If 295 physiotherapists (from four countries) cannot even agree on which is the best sitting posture, then how can the average person know what is? 

Other than having the physiotherapists do a back beliefs questionnaire (BBQ), the above mentioned study had a range of nine sitting options ranging from slumped to upright sitting. 85% of the physiotherapists surveyed selected one of two postures as 'best', with one posture being selected more significantly than the other. 

However, those two frequently selected postures were very different to say the least. The physiotherapists who selected the more upright posture had more negative low back pain beliefs in the BBQ. The main differences were what constitutes what a 'neutral' spine is and what is the best sitting posture is.

If you are slouching at your desk, almost everyone will tell you to sit up straight and watch your back. This is especially so when bending forward or while lifting. Back in 2019, I first suggested that slouching while sitting is not necessarily bad for you, challenging society beliefs about posture and back pain

So many companies have spent money on ergonomic programs to prevent back pain. This would usually involve a health professional/ physiotherapist (trained in ergonomics) checking your office chair/ desk height, screen height/ position with respect to your keyboard/ mouse to ensure everything is lined up in a straight line.

However, there is very little evidence linking back pain to poor posture. Oops, this basically means a huge profitable industry on work place/ home office ergonomics has very little sound evidence. 

All the published research to date has shown that there is no relationship between any postural factors causing back pain. This includes the shape and curves of the back, asymmetries and how we use our backs

Yes, if you already suffer from back pain, you may feel it more while sitting, especially for long periods. But sitting is not the cause of the back pain.

One of my patients told me that she just bought a two thousand dollar Herman Miller chair due to working from home 'causing' her back pain. It definitely helps with sitting up straight, however, it did not seem to help her back pain. That's why she still came to see me yesterday.

So, if you currently do not have neck/ back pain, you do not need to worry about your posture. If you do have pain, then your posture may affect it. Sitting for a sustained period is best avoided. The best ergonomic chair/ table will still give you pain. It is better to move more. Take breaks. Get advice and/or treatment to move with confidence and less pain.

References

O'Sullivan K, O'Sullivan P et al (2012). What Do Physiotherapists Consider To Be The Best Sitting Spinal Posture? Manual Therapy. 17(5): 432-437. DOI: 10.1016/jmanth.2012.04.007

Slater D, Korakakakis V et al (2019). "Sit Up Straight" : Time To Re-evaluate. JOSPT. 49(8): 562-564. DOI: 10.2519/jospt.2019.0610

Our spines have natural curves. It is not totally straight at all. You can see from the picture above that the neck is slightly concave, the chest area is convex while the lumbar (low back) region is again concave. In an ergonomic assessment, a 'good' posture usually refers to eliminating/ straightening out these curves.
Here are some common myths and facts about low back pain, slipped discs and your core muscles if you're interested in reading more.

Sunday, January 10, 2021

Which ACL Graft is Less Likely To Tear Again?

Post op -view from the front
In all my years of being a physiotherapist, I have treated many patients and athletes who tore their anterior cruciate ligament (ACL) and opted to have surgery to repair it. 

View from the back
In the earlier days, the bone patella tendon bone (BPTB) graft and the hamstring/ gracilis (HS) graft were the more popular choices. Allografts (cadaver graft) were not popular then, but they are definitely more accepted now.

I've had many patients (not just the athletes) who subsequently re-tore their HS graft. However, I have yet to encounter a patient who re-tore their BPTB graft.

If my observations were accurate, surely then the BPTB graft would be the 'better' and 'stronger' graft? Now it seems like there is evidence supporting my observations.

Researchers studied 770 patients (14-22 years) who were injured playing sports and had a six year follow up period. These patients had one normal un-injured knee and the injured ACL knee was reconstructed using the BPTB or HS graft. Average age of the subjects was 17 years, of which 48% were female.

There were 492 (64%) BPTB grafts and 278 (36%) HS grafts.

The chance of a subsequent  tear on the same reconstructed knee at six years was 9.2% compared to 11.2% in the uninjured normal knee. If it was either knee, the rate goes up to 19.7%.

The three most likely predictors of a subsequent re tearing of the operated knee were knee ligament laxity prior to knee operation, graft selection and age.

Those patients who had a HS graft were 2.1 times more likely to re-tear their ACL graft compared to those who had the BPTB graft.

Choosing your graft after tearing your ACL will definitely be influenced by discussions with your doctor, surgeon and physiotherapist etc. Moreover, besides the BPTB and HS grafts, you can also use an allograft (cadaver) now. 

Please bear this information in mind if you were to tear your ACL. Please come talk to us if you have any questions.


Reference

Spindler KP, Huston LJ, Zajichek A et al (2020). Anterior Cruciate Ligament Reconstruction In High School And College-age Athletes: Does Autograft Choice Influence Anterior Cruciate Ligament Revision Rates? 48(2): 298-309. DOI: 10.1177/0363546519892991.

R knee

Friday, January 1, 2021

Health Trends For 2021

Straits Times 1/1/21

Great suggestion in today's Straits Times article on the back page (B16, under Sports section) where the author suggested having more local running events for women.

I say not just more races for women only, but men and those under 21 too. In a year where most if not all running races were cancelled, runners are starved for social interaction and a chance to clock a personal best time for some or be quick enough for that elusive Boston qualifying (or BQ) time.

Perhaps with the rollout of the vaccines making exercising in enclosed spaces safe again, people may still want to go back to gyms, yoga studios and fitness centers etc.

I'm hope I'm wrong for the sake of those businesses, but I think gyms, yoga, Pilates studios may not be totally out of the woods yet. Bike shops, cheap dumbbells and other home exercise equipment will definitely continue to be in hot demand. Since March 2020, where most the world started lockdowns, too many people have learnt how simple, cheap and safe training at home is. 

I'm predicting that running, cycling, long walks and roller blading will continue to be popular in this new year. Let's all recognize the benefits of our local parks, bike lanes, park connectors and green spaces. All these spaces definitely impact our health.

A lot of us started baking, cooking and even growing our own food since the lockdown. All are healthy trends and may we continue to do that.

Let's continue to support our own local communities, the smaller shops and restaurants as they battle to carry on. We bought all our Christmas and birthday gifts from Everyday Vegan Grocer and Le Matin.

Here's wishing all of you a safe, healthy and wonderful year ahead.