ABR technique – origins, reasoning, implementation - 3Q Principle
Extracted from a Lecture
to medical professionals by L. Blyum at University of
Sydney, Holme Building, on Feb 24th, 2009
………I hope that by
now you can see how the pieces of the puzzle are starting to come together:
We have already
covered the distance from the complete neglect of visceral fascia by a classic
biomedical model to the realization of visceral fascia’s essential role in
weight-bearing of Cerebral Palsy children to the understanding of what kind of
mechanical impact we need to deliver in order to strengthen the visceral
fascia.
But we still have
few more hoops to jump before really developing a practical toolset capable of
reliable delivery of such a visceral fascia strengthening and improvement of
compressional strength of a body..
Let’s discuss the
next set of technical challenges one
faces when having the intention to address the visceral fascia.
·
These internal structures that we want to address are exactly that –
internal. They are deep inside,
situated behind the wall of superficial layers and we are outside. So the
obvious issue that we are facing technically is how to deliver that desired
1-2% repetitive slow deformation to internal visceral fascia from the outside
without being stopped, bounced back or having our impact absorbed at the
surface.
And sure there are
some other tricky aspects as well.
·
Our target layers of visceral fascia are involuntary so we need to induce their automatic response
because we cannot rely on their voluntary ‘exercising’.
·
Another important aspect to consider
is orientation – layers of internal fascia are arranged
in a somewhat spherical/ circumferential
manner instead of a longitudinal orientation of the superficial muscles that
everyone is used to and familiar with. All these technical challenges need to
be solved at least in principle before we can devise any practical way of addressing
the compressional weakness of individuals with cerebral palsy.
How do we deliver
the impact from the outside in such a way that we would be able to get some
meaningful response and consecutive strengthening of the visceral fascia core
over the course of time?
As a person with
manual therapy background, I was always led by the tactile sensation as a
primary mode of judging the response of the target tissues.
We already
discussed that the strengthening remodeling requires the generation of controlled
surface tension within layers of target weak fascia (that 1-2% deformation that
laboratory finding indicate).
Human hand is able
to distinguish the depth differences within the fractions of a millimeter and
with years of practice it develops into a sophisticated and reliable tool
capable of perceiving finer grades of compressibility and tension of target
layers. Fact is – that is how I developed the ABR technique and was able to add
continuing improvements to it through the years.
However, justification,
explanation and visual presentation have always been a challenge, making
communication with healthcare professionals extremely difficult – we were
referring to a completely different set of experiences.
But within the last couple of years, since the
addition of Mr. Mark Driscoll to our ABR team – Mark is a Biomedical Engineer
now completing his Ph.D. in spinal modeling in Montreal – there he is in a 2nd
row – we really have got much stronger in the department of biomechanical
modeling and today that really helps to explain with greater clarity the way the
ABR technique works.
Frankly the
following slide is one of my favorite illustrations of all time.
We discussed with
Mark the model of the ABR movement in details for quite some time and then he finally
went off for a few weeks working on it and programming – really zooming in … and
when he brought his results back – I was absolutely floored – everything was
just so amazingly clear, leaving no room for second-guessing.
So, this particular
slide gives you a very clear idea of what is happening throughout the ABR
movement.
The
model on the left is of non ABR movement:
When
the stiffness/density of the transfer medium does not match with the target
(the transfer medium is too stiff in comparison to the weak target layers), then
the entire external impact is lost within that stiff mediuam and there is no
useful strengthening impact delivered to the weaker (less stiff/dense) inner
layers.
The model on the
right is of ABR
movement: when the force transfer medium has minimal possible stiffness/density
so as to match the weakness of the underlying structure (target layers of weak
fascia). In such a case the force input bypasses the stress shielding effect of
the stiff/rigid shell and reaches the inner tissue.
Let me elaborate a
bit more on this terminology since most of it probably sounds very unfamiliar
for you.
Prior to venturing
into the details of the model on this Powerpoint slide and load you with all
these terms from physics: stress shielding; force transfer medium; matching/
non-matching stiffness etc., let me do a bit of a recap of the task in hand:
Let’s look at this picture of a human body as a reference assisting the work of your mind’s eye:
The key idea is
that if we are outside as a source of external force/impact and if we want to address
the internal volume and deliver at least some minimal stimulus to those inner
target tissues, we need to get past the outer shell. And the harder the outer shell, the greater the
stress shielding effect that it gives.
In a nutshell stress shielding effect works like this:
The softer inside
is always protected by the harder outside:
If there is an
external mechanical impact delivered at the consecutively layered structure,
the harder outside layer (‘a shell’)
absorbs this external impact thereby shielding the softer inside structure from it.
In respect to our
task in hand such a stress shielding effect by the outer body layers makes mechanical strengthening of the inner weaker
structures impossible.
Stress shielding
effect explains why the hundreds of compression techniques that existed before
ABR did not achieve the same effect of strengthening the visceral fascia.
Let’s put it simply:
if you do not specifically optimize your technique for the task of targeting those
weak internal compartments, you should not be surprised that you do not get
any strengthening effects. Your hand impact is being rebound or remains
superficial..
I mean, obviously,
ABR is far from the first compressional technique on the face of the planet.
There were and there are tons of them. As of today there are over six hundreds
compressional devices registered with the FDA in America alone and manual compressional
methods have been around for ages.
The natural
question that comes to one’s rational mind is obvious: “Why those existent
compressional methods fail, being unable to reach those
compressional weaknesses within efficiently?”.
Well, this failure of existent compressional techniques and devices is
caused by the stress-shielding effect that these techniques do not recognize
and do not adjust to bypass it intentionally.
ABR might be not
the first compressional technique as such but it’s the first one specifically
designed with the intent of bypassing the stress shielding effect of the dense
superficial tissues.
Let’s get back to
the specifics of bypassing the stress shielding effects, referring to the same PowerPoint slide in
order to understand what’s happening in better detail.
1. 4th
level, the lowest (deepest) level i.e. a ‘Target’, that is weak inner
“hidden”/protected tissue that we want to address, i.e. to deliver maximum
mechanical input to this tissue whilst respecting the minimal (1-2%)
deformation rule.
2. 3rd
level, is the outer structure: this is a hard ‘Shell’, which is an analogue of
the dense/ stiff superficial musculoskeletal layer. Hence if we speak about a thorax then this level is the ribcage as a shell
around its visceral contents..
3. 2nd
level, Force Transfer medium itself: It
is the “construction” through which we're trying to deliver the impact to the
underlying target layers. This medium is the only variable in this
model. (between the pictures on the Left and on the Right). All the other
parameters – Levels 1,3,4 remain unchanged.
4. 1st
level, which is the Force Input: It is a hand or a compressional device or any
other source of external mechanical impact.
The
model description is quite straightforward:
We
analyze the way that this Force Transfer Medium transfers the impact to the
levels 3 and 4 a Shell and a Target
depending on its construction and composition, i.e. the material, layout,
thickness etc. The model’s goal is to find out which medium provides the best
transfer of external impact to the Target (level 4) assuming that the Force
(level 1) is the same.
This
PowerPoint slide is color coded – the
deeper is the blue the greater impact is being transferred.
·
In the first model (on the left): when
the stiffness of Force Transfer Medium does not match with the target, there is
no impact delivered to the inner tissue – no deep blue to be seen...
In
other words, if the density/stiffness of Force Transfer Medium is greater than the
density/stiffness of a Target that we have inside, then everything stops at the bottom of the Force
Transfer Medium level never reaching the deep layers. That’s
the challenge what non-optimized compressional techniques face.
·
In the second model (on the right):
when Force Transfer Medium has minimal possible density with the intent of matching the weakness of an
underlying Target structures (level 4), the force input bypasses the stress
shielding effect of a Shell (level 3) and reach the inner tissue.
The
blue color is really deep there meaning that the external Force impact is
successfully delivered to a Target layer managing to bypass a stress-shielding
Shell on its’ way..
That’s exactly what ABR technique is based
upon – in practical implementation we look for the Force Transfer Medium that
has the best match for individual weakness of a particular person.
That’s
the reasoning behind those piles of towels and other textiles and synthetic
fibers that you have seen on ABR
technique pictures
This strange Stress
Shielding effect exhibited by a rigid external shell is not really something
totally new or surprising. It is well known in the other fields, engineering
and medicine included, – for example in artificial joint implants
manufacturing; and the general principles of bypassing it are very much
understood as well and have been applied in those fields – but never in manual
therapy or physical rehabilitation.
The unfortunate reality
of today is the fact that modern healthcare is gadgets driven and anything ‘manual’
is turned away right at the gate, being thrown into the basket of being
non-scientific, non-verifiable, purely subjective by medical instrumentalists.
The understanding of the necessary properties
of Force Transfer Medium brings us back to this fundamental idea why ABR uses all
this odd and strange textile constructions in between a hand and a body. I hope
it starts making sense by now.
If we want to
deliver this mechanical stimulus to the internal visceral structures that we are
interested in, we must achieve a proper match between Force Transfer Medium and
a target, which is weak internal fascia.
For the impact to be transferred into a weak
internal structure, the weaker the structure that we are targeting, the softer
the medium has to be.
And if one tries addressing weak, soft, easily
compressible tissues through a hard Force Transfer Medium, all the impact is just lost in an outer shell– nothing reaching
the deep weak target.
That is clearly
illustrated by this model.
Hence the Force
Transfer Medium is the towels + other textiles/ foams.
If we face a hard
outer shell (say, chest wall) separating us from the target weak internal
layers and if we were to use the transfer medium not matching those target layers in density, then we cannot get much impact
through and we just waste our external effort.
Question from the floor:
How do you determine the
exact “weakness” of the inner tissues? You are not measuring them with
instruments, are you?
Answer:
Sure we don’t. To be precise, even if there was a way to measure the stiffness
of an individual layer of visceral fascia that would not have any practical
value anyway. We have to think in
aggregates.
Let
me give you an illustration to facilitate understanding. Imagine a sea vessel
floating in the water. The sea water is denser, fresh water is less dense.
Depending on a mineral content dissolved in water its density increases or
decreases. Depending on a water temperature, its density increases or decreases
as well, right? These density changing factors can reinforce or partially
cancel one another; plus, we should remember that each of them influences water
density in non-linear way… All of those factors do make the equations more and
more complex, correct? If we were to try to figure this water density change by
measuring water temperature and mineral content directly then we’d need really
a lot of data and complex formulas in order to do that. However, the accuracy
of our prediction about water would still depend on the units of volume that we
use for measurement. So we’ll never know the exact answer even if we are able
to measure the density of a target medium directly. Do we need all that?–
Fortunately not.
There
is an easy way – buoyancy, that’s the main thing that matters for our
ship.
We
have to adjust it to neutral buoyancy in the very beginning and then we’d be
able to observe the change of density within the underlying waters simply by a
change of buoyancy – that’s an aggregate integral factor.
It’s
the same thing with ABR technique. Depending on an aggregate stiffness of an underlying
body volume we’d need to have adjustable Force Transfer Medium to begin our
compressional movement from a starting position of neutral buoyancy.
The
weaker the underlying body volume is – the softer Force Transfer Medium we need
to create in order to avoid sinking. If we have managed to adjust to a softer/ weaker target, than surely/ automatically we’d be
able to address denser/ less weak targets through the same soft Force Transfer Medium as well.
If
we were to get back to the nautical analogy – the ship that floats in less
dense warm fresh water is sure to stay afloat in denser cold sea water. But the
opposite is not necessarily true.
That’s
exactly how the ABR technique evolved – incorporating less and less dense force
transfer mediums allowed addressing weaker and weaker visceral fascia targets –
in practical terms it meant a usage of yet softer and fluffier textiles, then
adding various proportions of synthetic foams and I am constantly on lookout
for new materials. If one is concerned whether a person delivering ABR
technique is capable of feeling that neutral buoyancy sensation – I’d challenge
you to imagine yourself swimming/ drowning in the water and then ask yourself a
question whether we humans have a built-in sense of buoyancy or not?!
On
a more specific note, it is well proven that the human tactile sense is able to
distinguish the compression/depth differences that are just fractions of a millimeter.
That refers not to some mega-trained superhumans but to most average
individuals. That’s why the sensation of neutral buoyancy, which is the key for
the ABR technique, has a really impressive calibration on par with the best of
industrial production standards.
Our
experience clearly proves that. We have a range of students from 13 year old
siblings of Cerebral Palsy kids to 80 year old grandparents – all of them being
able to deliver consistent quality of ABR technique.
An
amazing precision of a tactile depth perception in an average human being gives
us another important benefit – high consistency and repeatability of ABR
technique delivery. Although ABR technique is manual it relies on the senses –
depth and neutral buoyancy perceptions – that are pretty much uniform among all
of us and do not differ significantly from a person to person.
So with these ideas
in mind let’s get back to the ABR technique itself and talk about some
must-have components that are necessary to succeed in order to be technically
capable of reaching the visceral hydraulic core with fascia strengthening
intent:
·
First,
we really want to get the right force transfer medium. That's an absolute must for
having an efficient delivery of mechanical stimulus to target inner fascia
layers.
But if we are
dealing with the soft Force Transfer medium (Level 2) ‘sandwiched’ in between
the force input ‘plate’ (Level 1) and ‘outer shell’ of the body (Level 3), we
have to ensure that we are not going to sink into this Force Transfer medium
from above (Level 1). We want it to remain our consistent medium of
external force transfer instead of being just elastically depressed and
becoming a ‘medium of waste’. That's one
thing.
·
Next
important thing is
to recognize that we address the volumetric structure. Our target is not some selective muscular fiber,
not some selective easily identifiable longitudinal threads of muscles – these
are just one-dimensional objects. To strengthen the visceral hydraulic core we
have to mechanically address a chosen volume (compartment) with its sub-compartments.
Therefore
we have to organize our entire technique in such a way that it achieves response from this entire volume/
selected compartment without altering/ distorting it’s surface shape by sinking
in it.
In summary, when
designing the technique capable of strengthening the visceral hydraulic core –
these are the negative phenomena we have to avoid at all costs:
·
over
compression of Force Transfer Medium
·
elastic rebound, of Force Transfer Medium or ‘outer shell’
·
‘outer shell’ surface distortions
·
any potential traumatic effects (even
the microtrauma);
All these
requirements put together bring us to The Principle that is the technical
basis of ABR – called the Triple
Q or 3
Q Principle –
1st Q – Quasi-static,
2nd Q – Quasi-spherical, and
3rd Q – Quasi-isotropic.
These are some
heavily sounding words, but please, have no worries – in fact everything is quite
simple.
Quasi-static means super slow
movement. We would see in the later
model that the best way to deliver maximum input to the internal weak tissues
is through super slow movement.
Quasi-spherical
means that since we intend to address a large volume we then need to maintain a
sufficient area of surface coverage throughout the entire duration of our application
(avoiding local ‘sinking’/ depression into a Force Transfer Medium).
Fortunately, in order to address a total
volume of a certain compartment of a human body
we do not need a complete surface
wraparound; there is no necessity in
surrounding a person with one big “hug and squeeze”. Quasi-spherical principle simply points out
that we are obliged to have a certain minimal area of contact, sufficient for getting
a volumetric response. If this
description is not entirely clear – I am sure it will become obvious once we go
through the respective model.
And Quasi-isotropic means that we don’t
want to deform any of the surfaces throughout our application – neither a Force
Transfer Medium layer nor an Outer Shell layer because any deformation of
surfaces causes the loss of that force transfer effect to the deeper weaker
target compartments/ layers.
Let's look at the
models, which confirm these three basic principles.
The
model on the left is the model with the local compression on the surface of the
Force Transfer Medium.
The
model on the right is the model which shows us the widespread force application
that involves the total volume.
If you look at the
figures in the model, the impact generated by the model on the right is nearly 600 over times larger than the model
on the left.
(0. 0600 impact
range is ~600 times greater than the 0.0001)
Basically, the
model on the left shows that if the impact is local and superficial, no matter
how much force one generates from outside, all that force is simply lost and
wasted .
The ribs could be broken, and damage could be done, but still no
strengthening impacts are is being
delivered into those weak visceral membranes that we target through this
application.
On the other hand, as
shown by the model on the right, if we deliver the widespread application, the
efficiency of a force transfer to the target deep layers increases
600-fold.
That is one impressive
finding, which is very counterintuitive.
Most people assume
that the more force we use from the outside the more will eventually get
transferred inside. In other words, intuitive thinking is to connect harder
“pressing” with greater delivery inside.
Well, apparently
that’s wrong – increased efficiency of
internal strengthening has very little to do with absolute magnitude of force
that a practitioner delivers. Yes, sure, some minimal force is required but
any further increase is not only unsafe but useless altogether.
The geometry of application is much more
important for the efficiency for strengthening than the force itself.
I’d like to
emphasize that in these models and the ones that follow, there is no particular
specification of how much force is being used.
The key element is the rate and the key idea is the percentage of efficiency indicating that a practitioner has to work smarter – not harder. It is important to know that no matter how hard you squeeze, you're not going to get much internally if the application is only local.
I
have been asked a couple of times about the compressional techniques that are
administered for patients with cystic fibrosis. These people, in, Scandinavian
countries where healthcare is free of charge, get 2 to 3 hours of physical
therapy a day for years, and their therapy involves the compressional chest
techniques.
Aren’t
these people getting some quasi ABR application? Why then they are not getting their chest
volumes developed and rib cage elasticity improved benefiting from extra compressional
strength following such an intensive exercise regime?
I
address this question by pointing out that compressional technique for cystic
fibrosis patient is intended to get some elastic response of the chest wall and
try to make them expectorate some accumulated mucous.
The
previous models explain why visceral fascia strengthening can only be a product
of deliberate intentional targeting, it’s almost impossible to have this
strengthening effect accidentally. The techniques that are not specifically
designed with bypassing a Stress Shielding Effect in mind do not really work
for long term strengthening even after hundreds of hours of mechanical
applications.
Next we're discussing the importance of the
composition of the Force
Transfer Medium that we are using.
Again, please pay attention to this, external force is the same but the impacts
on the body are different.
This model takes us
further along the ABR technique path.
Once we accepted the idea that force transfer
medium has to be present as an absolute must if we are to have any chance of
delivering the internal tissues strengthening, the next step is to figure out
how to optimize that Force Transfer Medium.
This model gives us
further clarifications of how much does a difference in results depends on how
well we have constructed that strange pyramid of towels and other textile
substances placed between a working hand
and a body of recipient.
This model is
pretty much self-explanatory and points out that even mini-variations in the density of the layers
that compose Force Transfer Medium
can result in up to 4 times the
difference in terms of magnitude of response of the deep weak fascia layers.
This model also reinforces
the Quasi-Isotropic
principle giving it a dynamic depth perspective. This
model points out that having initial uniform contact with a large surface area
is an important first step in the ABR technique but we have to look beyond it.
The smoothness of the further compression through the Force
Transfer Medium has a significant role as well. Therefore a non-uniform (jerky, slanted etc.), so called anisotropic application ends up being
less efficient than a uniform one.
The next model discusses
the importance of a relative velocity of compressional movement for a technique
aimed at the deep internal layers, supporting the Quasi-static principle of the ABR
technique..
This model represents the variable stiffness of tissues
that we target when aiming for hydraulic visceral core at the chest area
through consecutive springs with a corresponding difference in Young’s modulus:
1 -Force Plate; 2- Force Transfer Medium; 3- hard/ elastic ‘Outer Shell’; 4 – Target
weak inner layers . .
Let’s have a look at the results of the
calculations.
I wouldn’t bug you
with too much of math stuff – you are very welcome to get in touch if you want
to have a more detailed inquiry into any of the models – let’s proceed straight
to the conclusion.
I find it very
impressive:
The slow movement delivers movement up to 19
times more of the impact throughout the consecutive tissues of variable
stiffness than the fast one.
I hope that this model clarifies the reasoning
behind the ‘strange’ appearance of the ABR movement that is super slow and
super-long lasting up to 20-25 seconds.
Again, there is big difference between hard work, which is very much wasted on the surface, and the specific delivery through the quasi static motion.
Conclusions:
I quickly walked you through the main components of ABR technique:
·
Low-stiffness
(“supersoft”) Force Transfer Medium as the key
ingredient in making it possible to transfer the impact that comes from a hand to
the targeted weak inner tissues. In real
life I have settled for a “textile pile” as the composition that empirically
turned out the most suitable with the right mix of ingredients.
ABR Technique Principles:
·
Quasi-Spherical–
wide surface of coverage justified by a huge advantage in efficiency that it
has over the local pointed application (up to 600 times)
·
Quasi-Isotropic–
uniform contact and uniform compression justified by the fact that even minor
irregularities within Force Transfer Medium during the movement lead to the
loss of the efficiency.
·
Quasi-Static
– superslow movement justified by huge advantage in efficiency that it has over
the fact application (up to 19 times)
And let me remind
you where all these technical tricks stem from:
One is forced into
the search of unorthodox solutions due to the ‘tricky’ nature of targeting the
compressional weakness because visceral hydraulic core has internal,
involuntary, circumferential layout as opposed to the external, voluntary,
longitudinal properties of skeletal muscles and superficial fascia that everyone
is familiar with.
….
I am expecting that
by now we are well past your first “surprise” reaction to seeing the ABR
technique in action when it was something more like:“What on Earth is
T-H-A-T??”.
I do hope that once
we went through these key ‘ingredients’ of the ABR method it makes a lot more sense
and you are able to see that each of those “strange” and unorthodox technical
moves is purpose-driven and intentional in design.
As a person with a
math background I was happy enough to practice and fine-tune the ABR technique
based on this level of aggregates – neutral buoyancy at Force Transfer Medium
plus 3Q principles without really being bothered too much with the exact
micro-structural details of how exactly does the fascia undergoes the
strengthening and remodeling process.
Frankly, for me it was
quite straightforward – as long as I know that fascia is capable of remodeling
and that it was shown by some clever and responsible people in the labs that
this particular “strengthening” type of remodeling is within this 1-2% – that
information is sufficient enough for the effective fascia strengthening
technique design.
My task is to
deliver the right impact to the right place in the right mode – that’s it.
Whatever are the exact histological/biochemical particulars that make the
remodeling occur –it has no practical value for me since the technique is
delivered at the macro level of large compartments of a human body.
However, as I
communicated more with healthcare practitioners, I realized that there is a big
difference in mindsets. You guys tend to place a lot of importance on the
understanding of the elementary micro-level processes that are behind a certain
macro-level transformation – so I am going to provide that level of detail as
well.
Before we proceed
to that – there is a little disclaimer. Obviously, we have not done any
laboratory histological/biochemical studies ourselves, so the next chapter is
based on a literature references and reviews, which we found applicable to the
subject of fascia remodeling/ strengthening.