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.
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.
Basically, ABR technique in action is this Force Transfer model which is being re-translated it into practical implementation tools, which turned out to be all of these textile- and foam-based constructions.
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:
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.
Well, first of all, the ‘Application Area Model’ confirms the importance of having the widespread contact area and the Quasi-spherical principle as well as the Quasi-Isotropic principle of the technique.
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 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.
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.