Ryan Hayes RMT

Let the Tissues do the Talking.

Manual therapy sits in an unusual position in healthcare: we assess with extremely variable measuring devices (our hands) and often take this information as fact without either reason or validation. Therapists aren't using technological visual aids like MRIs, ultrasound, and x-ray. Yet, with our limited knowledge and understanding of the actual internal physiological milieu, we make sweeping statements to patients about what is causing a problem.

Manual therapy also puts too much weight in the subjective experience of the patient: symptomatic presentation and assumption of cause can have slim to no overlap. In many cases, there are numerous layered factors making it irrelevant to try and establish just one. However, these are the things on which we hang out hats. Should therapists treat how the patient feels, what assessment reveals, what we feel is intuitively right? Neither.

In short, we are supporting:

1. the "emotions" of the local tissue - providing empathy for specific anatomical structures and establishing cohesion with the immediate neighbours

2. the local communities within a region of the body - making sure that individual areas are integrated into a broader area, such as a knee to the whole leg

3. the global picture - reintroducing the regions to each other allowing for systemic efficiency where everything has its place and supports the whole

We must consider that the body is a functioning organism; injury to one area will affect numerous other areas and systems.

Pain and Symptomatic Presentation:

Pain is subjective. We cannot treat pain. Symptoms don't necessarily indicate causation. We can only treat tension and what the body gives us permission to access. Practitioners should normalize position and movement in broader regions rather than symptom-specific areas. There is much discussion on social media about pain science. Understanding pain mechanisms has a place in manual therapy. However, the nervous system is good at misdirection.

Putting all of our trust in what patients say is ill-informed clinical decision making; it is akin to trusting a witness to recount all the details of a crime: the information is important, but it usually doesn't tell the whole story. As experienced clinicians, therapists must merge what they are told with what they find present within the body. Therapists must also be aware of distant anatomy that may be contributing to the presentation of the patient.

Generally, our first objective is to resolve pain presentations. Therapists must be cognizant of the fact that presenting pain symptoms may have been building through adaptation and compensations over years in the making. The longer the problem, the more likely there are systemic implications to the problem. We have to use keen observation, palpation, and judgement to blend anatomical discrepancies with symptomatic presentation.

Thyxotrophy:

Thyxotrophy refers to the nature of the fluid-like ground substance inside fascia and the extracellular matrix. While becoming more fluid when either shaken, stretched, or warmed up, it becomes more structurally solid with either aggressive, intense, or rapid applications of pressure. This becomes extremely valuable when trying to apply deep tissue techniques. If these techniques are forced onto the tissues, they will likely respond with resistance.

Navigating the thyxotrophic aspects of tissue requires a mutual give and take. Much like a conversation, the practitioner must learn when to listen and when to speak. Too much pressure too soon will mitigate attempts at gaining access to deeper structures. In most cases, patience is required to facilitate entrance. It is the tissue rather than the practitioner that dictates the flow of conversation.

Cleaning House:

The body has a naturally built-in healing process. In most cases it functions efficiently to help the body return to a state of homeodynamics. In cases such as stress, trauma, and pathological disease states, the allostatic load may be too much for the body to manage. The manual therapy practitioner can support these mechanisms to help restore the balance. However, support is not control. We have a responsibility to listen and help rather than dictate.

Think of this healing mechanism as a Roomba. The vacuum freely moves around until it hits a wall. It still knows that it needs to clean after it finds a way out of the predicament of being blocked. The body has these same innate tendencies built in. Our role is to aid in removing the blocks so our physiology can get back on track and restore the body back to health. We are not the ones doing the healing. We prep the floor to be cleaned without hindrance.

The means of doing this is by following the lead of the body. The therapist can observe the direction the body is trying to go and aid in removing the block that impedes it from getting there. The integrated systems of the body are not simply a chair leg or a closed door. However, with attentive touch, astute knowledge of anatomy, and experienced clinical judgement, we can support the body with much more effect than just random guesswork.

Be clear of a desire for a result. Be clear of dogma. Be clear. Be. - Hugh Milne

Manual therapy aims to find root causes; it aims to fix; it aims to remove pain. This is not our role. Our role is to support. Our role is to unblock the means by which the body cannot function at optimal capacity. We redirect. We partner. We are not in charge of healing. If we believe we know better than the body, we have already lost the battle. In whichever role we fill, we work synergistically rather than autocratically.

Safety is Stressing Me Out!

There is a multitude of modalities these days selling patients a "neurological reset." Manual therapists advertise that chronic stress and chronic pain can be reversed by creating a safe space for the nervous system to relax; the body has been living in a danger state for so long that only we can provide the impetus through our treatments to let the body feel safe and heard. This is a dangerous lie that misinforms the people who trust us the most: our patients.

FIRST, a brief biochemistry and physiology lesson...

Stress Management:

The HPA axis provides the primary neuroendocrine response to acute and chronic stressors. This is a complex negative feedback system that includes the hypothalamus, the pituitary gland, and the adrenal glands. The stimulation of neuroendocrine release through HPA axis activation is not confined to physical trauma alone. The acute stress of major life events and chronic stress accumulation over time can both instigate the neuroendocrine mechanism.

When the HPA axis is not performing optimally it can impose numerous deleterious effects on the individual affecting several specific body systems. For example, the cardiovascular system has an affinity to negatively react to prolonged dysfunction of the HPA axis. Also, the response of the immune system is dampened with HPA axis activation due in part to the function of cortisol.

The term "adrenal fatigue" is often used to describe the end result of HPA axis dysfunction. While it is true that there may be less production of cortisol and DHEA (dehydroepiandrosterone), the adaptation often occurs higher up in the neurological chain of command. Typically, the origin of dysfunction lies with either the hypothalamus or the pituitary gland.

HPA Axis Regulation:

The HPA cascade is a complicated system of direct influence combined with feedback loops between the hypothalamus, pituitary gland, and adrenal cortex. Other vital influence on the HPA axis comes from higher brain centres: the prefrontal cortex, amygdala, and hippocampus add a layer of complexity to HPA axis function. The HPA axis cycle commences following stimulation by the amygdala.

Subsequently, the hypothalamus interacts with the pituitary gland, which then sends signals to the adrenal glands. When the adrenal glands become activated, they release hormones and glucocorticoids (GC) to defend against the incoming stressor. The HPA axis cycle concludes when enough GCs have been released into the bloodstream. This influx of GCs closes the negative feedback loop that prevents more cortisol being produced.

The Endocannabinoid System (ECB):

The ECB has been acknowledged to be a key mediator in human pathophysiology. Regulation of the HPA axis is optimized through the ECB. The central ECB is a neuroactive lipid signaling system that resides within the brain. This system has become a site of research for treating psychopathologies that result from stress. There is much evidence to support the notion that the ECB regulates the HPA axis.

This evidence infers that ECB signaling is also a participant in the HPA axis response to stress. The ECB has also been recognized as central to emotional memories, hormone secretion, pain modulation, as well as involvement in memory consolidation, retrieval, and extinction. The ECB negatively modulates the effects of stress on the sympathetic nervous system, HPA axis, intrinsic feelings, mood, and anxiety.

Why Does it Matter?

It matters because we seem to believe we can correct these systems with our soothing words, our well-placed techniques, our behavioural modification, and our breathing exercises. Even if it were possible, it would take a team of people a good chunk of time to establish long-lasting change. This does not mean we shouldn't consider the nervous system; it means we should exercise extreme caution in relation to overstating what we can realistically achieve.

Manual therapy has become a grey area of marketing, money making, and unsubstantiated modalities. Flowery narratives make claims about treatment outcomes that aren't either rooted in anatomy or supported by scientific research and evidence. Health has become big business! While things may sound good on the surface, we should use sound judgement and critical thinking when considering what we tell patients.

There is no doubt that manual therapy can influence all of the different systems of the body. However, to presume that we can right the wrongs of the HPA axis and the ECB in a neurological reset is unfounded and disingenuous to patients. We must come to terms with the limitations of our skill and of our professions. Otherwise, not only are we deceiving ourselves, but we are deceiving those who trust us with their health.

Absolute Brilliance or Absolute Blechschmidt.

I am neither a histology expert, a cytology expert, nor an embryology expert. However, I am a curious manual therapist. During the last quarter of a century, I have been studying how best to implement information received from the body. After much time and even more reflection, I find the questions I ask myself get bigger and bigger. I have always believed embryology plays a significant role in the corpus of manual therapy. As such, I considered:

Do the cellular fluids of the body demonstrate Intelligence?

In consideration of this question, we have to go back to the onset of development: the embryo. In "The Ontogenetic Basis of Human Anatomy," Erich Blechschmidt maps the kinetic, metabolic, and biomechanical principles of human development. Blechschmidt introduces the idea of biodynamics. In his work, Blechschmidt uses human embryos for his research as opposed to the more commonly derived physiological explanations using animal models.

We must also be clear about use of the term "intelligence." Intelligence is defined as the mental power to learn, understand, reason, solve problems, and adapt to new situations. We can make the case that fluid movement solves the problem of boundaries. We can also make the case that fluid dynamics adapts to new situations. Is this intelligence? Not by definition. It is more akin to the intelligence of a river in carving through a valley.

Erich Blechschmidt:

Erich Blechschmidt (1904-1992) was a German embryologist who built a collection of human embryo models. Housed at the University of Gottingen in Germany, the collection contains hundreds of human embryos and fetuses. The collection also possesses unique life-size models of human embryos. The contents of Blechschmidt's research and physical representations of his work are globally unique.

Blechschmidt's concept of biodynamic forces is primarily based around fluid movement, metabolic shifts, and developing pressures. In his work on biokinetics in differentiation, he demonstrated that genetic activity reacts to physical and hydrodynamic environments. He discovered that protoplasmic movement within the early embryo facilitated spatial organization and anatomical form.

Blechschmidt categorized the developmental stages into metabolic fields where differing growth rates alter local tissue tension. Consequently, cellular differentiation and tissue folding respond directly to physical forces like hydrostatic pressure. Blechschmidt believed that growth functions precede all higher functions, arguing that genes are themselves inert and thus react to the stimuli coming from the cytoplasm.

There are eight metabolic fields described by Blechschmidt to explain how cells, tissues, and organs change shape and position during development. For example,

- Suction fields create glands

- Densation and detraction fields create bones

- Distusion fields create cartilage

- Retention fields create tendons, ligaments and joint capsules

- Dilation fields create muscle fibres

Blechschmidt found that blood vessels act as restraining structures. This means that they act as mechanical barriers constraining and shaping differential tissue during development. In a broader context, blood vessels provide resistance that direct organ flow, slow excessive cellular proliferation in adjacent tissues, and guide spatial folding. This vascular border dictates where tissues either bend or expand.

Blechschmidt found that all organic differentiation is a development of position, form, structure, and function. For example,

wherever cells lie close together, extended perpendicular towards a free surface, they exert a mutual pressure in a lateral direction

organs differentiate whenever there exists both a spatial opportunity and a metabolic occasion

the suction field created by the growing/descending heart, liver, and vertebral column allows for the development of the lung

Metabolic fields and manual therapy:

Beginning at conception, our developmental journey to birth and beyond is a constant physiological flux. This biokinetic evolution shows that the embryo develops in continuous motion and that physical forces shape cellular differentiation. Cells respond to physical force. Although poorly understood, we know this through our manual therapy work. However, we can explore this relationship if we can ascertain where we need to provide a "metabolic force."

Outside-inside differentiation proves that outside mechanical forces from surrounding tissues dictate internal structural development. The aim of the practitioner is not development. The body knows this. It has long since moved on from development and is now working towards optimizing metabolism and health. There is a plan. We must work with this plan using our tool of choice: our hands. We provide the necessary outside mechanical forces of support.

"Find it, fix it, leave it alone" - A. T. Still

The key is in understanding how to communicate with this biodynamic force; interaction can occur from anywhere. The body is always in optimization to some capacity. There are priorities. The majority of the body is doing just fine. We simplify treatment to the most important and appropriate applications of the metabolic fields with which the body can create the desired result. Understanding this is a long journey. We facilitate the conditions for change.

In Closing:

We began life through changes in internal fluid movements and physical forces. These are intrinsic and vital forces for embryological development. These origins are instrumental in our applications of manual therapy. We can facilitate change with mechanical force. We have to ask how we can facilitate the best change for that person on that day. The body is already working on it. We are lending a hand... or two.

To Plan or Not to Plan?

Treatment planning is inherently challenging. In many instances, we don't know exactly what may be causing the problem that we are aiming to rectify. In other cases, we can't be sure how many anatomical players are involved. Both of these situations are compounded by how well we can effectively quantify contributing factors and treat some of the problems that they are creating. Much of this work is done without facts, proof, and evidence.

The Problem:

Often, patients come to us without a diagnosis for their symptomatic presentation. As a manual therapy practitioner, we are relied upon to recognize and resolve whatever is causing the problem. Depending on the manual therapy service, there may be a variety of different answers as to wherein the problem lies. This will create various different treatment plans depending on who is doing the planning.

As palpation and assessment are inherently flawed, the treatment target may also be incorrect. While the issue may stem from a localized source, we should broaden our assessment approach with the aim of noting other problematic areas that may be either causing or contributing to the problem. However, we would be remiss to assert causation as there are too many variables to consider.

Treatment Without Causation:

In a large percentage of cases, patients have pains that creep in over time. Many of these problems are an accumulation of stressors that have pushed beyond the capacity of adaption and compensation. When the allostatic load is too large, symptoms will likely present. In these instances, we shouldn't take the symptom as the cause of the problem. We must consider the systemic factors that may be far removed from the site of pain.

When we have discovered structures that seem to be dysfunctional in either position or movement, we can ascertain if we believe them to be part of the problem. Subsequently, we utilize the modalities and methods that we feel can return the body to normalcy. Depending on the problem, it may take several treatments before we find that we have facilitated a symptomatic change wherein we have accomplished all we can.

We cannot quantify the physiological effects of our treatment. Therefore, we have to hedge our bets that the techniques we choose will have effect. It may be that we complete several treatments without impacting the symptom picture. In this case we must re-evaluate our ideas about causation as well as the objectives of our treatment plan. A short-term treatment plan will allow us to reassess our progress and decide if we need to either modify or refer out.

Treatment With Causation:

If our patient has been given a formal diagnosis, it may allow an easier prediction of course correction. Certain pathological conditions may have a more structured plan that outlines a return to health. Treatment still has to be tailored to the individual and their anatomical presentation, but we do have a baseline of treatment that we may be able to follow; no treatment should be a cut and paste approach.

This type of treatment plan will be based upon the complexity and longevity of the problem. The sooner we begin with an issue the sooner we may get change. In all cases, it is helpful if the patient does their part between visits to sustain and support treatment effect. It may be that complex diagnoses require a team effort that is founded upon good communication and synergistic treatment. Sometimes a team approach is the best approach.

Know Who You are and What you Offer:

We all have strengths and weaknesses. We must recognize our biases and not let them become prescriptive. We must limit assumption. We must understand how we can help and what we can help. We must know when we need support. We must know when we have reached a plateau in treatment. We must consider any limitations on what we can effectively impact so as not to waste patient resources.

We must reflect on the outcome of our individual treatments to predict effects over multiple treatments. To do this, we must understand changes in tissue quality and mechanical movement. The skill of the practitioner may shorten the time of the treatment plan. It is always healthy to start with at least three appointments to see if progress can be made. After, we may need to either put the patient on a second treatment plan or begin preventative care.

In Closing:

A treatment plan is largely dictated by the clinical experience and skill of the therapist in quantifying the general state of health. This is easier to outline after completing a full treatment with observations also made from a hands-on perspective. The plan should be clearly explained and mutually agreed upon with the patient. We should remember that a treatment consistently needs to be updated to optimize patient and treatment outcomes.

A Body of Evidence.

Manual therapy is becoming a quagmire of misleading information, false narratives, and corporeal propaganda. Unfortunately, science and research have yet to explain many of the mechanisms involved in numerous manual therapy techniques. As such, a Cambrian explosion of modalities now claims to do all sorts of things that have no basis in truth. Many of these modalities substitute anecdotal evidence for fact.

Worse, many people pass off poor research articles as evidence of treatment efficacy. In many cases, people have misunderstood the article. They have either skimmed the Abstract or absorbed the Conclusion without thinking critically about whether or not it is a good research design. Presentation of a paper as proof of positive outcomes will be open to criticism. It can take decades for physiological mechanisms and treatment effects to be understood.

There is no doubt that manual therapy in its numerous forms has positive impact. Yet there is an inability to demonstrate consistent results that support the claims of different modalities. This is not limited to new variations on old approaches; the progenitors of present modalities are also not well supported in mechanical application and physiological effect. We should be getting more consistent results than we actually do. Why is this not so?

Consistency in massage therapy:

While there is a standard pedagogical approach to massage therapy, there is no requirement to upgrade skills once a student has graduated. This means a practitioner could go their whole career without taking a post graduate course. Practitioner skill, both technically and clinically, is widely variable; this calls into question the progress that can be achieved without incorporating new skills and knowledge into our practice.

Consequently, we have a proliferation of niche treatments, tangential approaches to existing modalities, and garrulous and unoriginal posts about the trend of the day. Often, these claims expound upon a new direction in manual therapy attached with an article that doesn't actually support the claim. Unfortunately, consistent results are challenging in research as there are so many variables to consider. We can't even agree on treatment of chronic low back pain.

This isn't to say that old modalities are not effective and new modalities are all skullduggery. In some cases, treatment has accepted effects without a clarified mechanism of action. In other cases, treatment may piggyback off existing knowledge that has not yet been verified in either methodology or approach. Certain mechanical applications may be understood, but not in the context being presented. Research cannot keep up with therapeutic expansion.

Separating fact from fiction:

We must think critically about new modalities. We must think critically about therapeutic claims. We must think critically about research proposed to validate specific techniques. This does not mean there isn't credibility in emerging treatments. However, we must refrain from disbelief and antagonism in exchange for active dialogue and transparent communication. We can use existing knowledge to apply known mechanisms to logical and creative applications.

While research continues to gain traction in manual therapy, social platforms and marketing continue to advertise the next quick fix. We should exercise caution over blind acceptance of new success stories. Evidence-based techniques, modalities, and mechanisms don't support many new claims. While this doesn't make the claims invalid, it does mean that questions can and should be asked. Language matters. Knowledge matters. Integrity matters.

A Bone to Pick: the periosteum.

The periosteum is a fibrous membrane that surrounds most bones. It is only absent at joint surfaces where cartilage is found and at major tendinous insertions such as the Achilles. The periosteum is composed of two layers. The outer layer is constructed of dense, irregular connective tissue. This layer contains fibroblasts, which makes it an excellent therapeutic target. The inner layer is adjacent to the bone tissue proper and contains osteogenic cells.

The periosteum is rich with nociceptors making it a potential source of pain. It is not uncommon for bones to receive impact forces that may manifest as either bruises, fractures, or shin splints. Shin splints can be a repetition injury created by faulty mechanics that direct force improperly and denature the periosteum. While it is imperative to restore the mechanics, it is also imperative to remove embedded tension from the periosteum.

The fibrous layer of the periosteum also contains blood vessels and lymphatic vessels that nourish, remove waste from, and provide immunity for the bone. Conditions that cause either trauma or inflammation to the periosteum can create pain. The tensegrity of the periosteum should be optimized as efficient fluid dynamics must be viewed as one of the most important physiological processes to minimize stagnation, congestion, and to improve healing.

Type I Collagen Fibres:

The periosteum is anchored to bone via Sharpey's fibres. These fibres also attach ligaments, tendons, and in the case of intervertebral discs, cartilage to the bone matrix. Sharpey's fibres are primarily type I collagen fibres. Type I collagen fibres are the most extensive in the human body. Collagen fibres establish tensile strength and mechanical stability to numerous tissues in the human body. Sharpey's fibres transmit muscular forces to the skeleton.

Due to its collagenous framework, it can be surmised that inefficient biomechanical function may cause unnatural force distribution either through or along a bone. This can manifest as tension within the periosteal layer. Therapeutic modalities can modify collagen through physiological and mechanical means. Direct pressure can disrupt abnormal cross-links and adhesions; mechanical loading can stimulate mechanotransduction nurturing fibroblast activity.

As type 1 collagen is found in tendons and ligaments, and tendons and ligaments are accepted as being treatable using manual therapy, by extension the periosteum is an area of the body that should be considered in treatment. While type III collagen is the dominant type within muscle fibres, type I collagen is found in endomysium, periomysium, and epimysium; this provides support, strength, and elasticity to muscle fibres and tendons.

Summation:

The periosteum is the fibrous outer layer of bone. It is constructed of the same type of collagen that is found in tendons and ligaments. This structure allows periosteal tension to be found through palpation. As manual therapy is a useful tool in treatment of structures containing type I collagen fibres, the periosteum becomes an excellent target for therapeutic intervention. With practice, it is easy to discover and remove tension within the periosteal layer.

Tension through the periosteal layer may conversely create tension in the ligaments and tendons that attach to it. Muscular tension may also be perpetuated through this anatomical connection via the extension of Sharpey's fibres into the bone. The inclusion of vascular and lymphatic structures within the fibrous periosteal layer makes it an attractive target for manual therapy modalities. Expand your evaluation to include tension in bones and see what happens!

Corporeal Mythology: the three Fates.

In Norse mythology, the three fates weave the threads of destiny for humans and gods. The Norns, named Urd, Verdande, and Skuld, live at the Well of Fate beneath the world tree, Yggdrasil. Urd represents the past. Verdande represents the present. Skuld represents the future. As the three fates weave the threads of our existence, the manual therapist aims to unravel those same threads back to perfection. That perfection begins with the embryo.

Like the triad of Norns, our embryological threads contain three primary germ layers: the ectoderm, mesoderm, and endoderm. The ectoderm primarily forms the nervous system, the epidermis, and most of the senses (taste, sight, hearing, smell). The mesoderm becomes the muscles, bones, connective tissues, circulatory and lymphatic systems, the urogenital organs, portions of the skin and internal body cavities. The endoderm becomes the epithelial linings of the digestive and respiratory tracts and associated organs such as the liver, pancreas, and thyroid gland.

The creation of the germ layers marks the beginning of our Fate. From this point on, the threads of the fates will intricately weave their tale expressed corporeally as the physical and psychological state of our existence. Not only do the individual threads get tangled, but all three anatomical threads entwine leaving a tangled mass of life experiences. The role of the manual therapist is to unravel the threads of past and present to allow an unfettered thread into the future.

Untangling the threads of tension:

When we consider the manifestation of tension, we must understand that this tension is a combination of the germ layers and their anatomical constituents. They grow together. They function together. They live together. Therefore, we cannot expect to treat one thread to the neglect of the others. The person we see on the table is the physiological summation of their extant being. The body is a diary of their physical and psychological existence.

What began as three individual strands has now become a convoluted ball. Our job is to take this ball and unravel the entanglement of the fates. However, the human body is much more complex than three pieces of yarn. This is neither a simple nor a short process. The more complex the problem the more entwined the yarn. The longer the life the longer the yarn. The fabric of the individual is woven into the tapestry of their cells.

A ball of yarn is not randomly created. The threads tangle in a very specific, but unfathomable way. We do not know the past until we have unlocked the present. We must unravel the threads in the way that is accessible to us in that moment in time. Like deciphering the map of a maze, there is a fastest way to the middle. The path may hit dead ends. There will be many twists and turns. Ultimately, there is a most efficient way.

"Superlative technique has its genesis in moment-to-moment perception of the client's channel of consciousness and his needs" - Hugh Milne

When we pick up one thread, we must acknowledge that it is attached to the whole person. A tension line may be long. A tension line may be short. A tension line may contain only one primary structure. A tension line may contain several anatomical structures. It is imperative to consider the continuity and expanse of any line of tension in order to comprehensively release it. We must gather the tendrils together and dissolve them.

These lines of tension will contain either the cause of that tension or the compensations and adaptations associated with other buried tension. With a chronicle of undocumented history, it is challenging to discern where it all began. Like a mountain range jutting high into the sky, thus can the layers of primordial history present as current symptoms. Be wary of a problem that has persisted for years: the global picture has evolved a new landscape around it.

Reconfiguring the landscape:

The threads of life represent a physiological timeline. The layers form the strata of a person's history. Much like a connect-the-dots puzzle, we can only navigate one number at a time. Only when that line of tension has been resolved will the next line present itself. Connecting all of the dots will complete the treatment picture for the day. We must leave the body in a place where it can reorganize and self-regulate. The analytical and the intuitive must be mastered.

Taoist Touch is interactive; that is, in Taoist Touch you begin to respond to the form and dynamics of the tissues in the way you think they are asking you to, not how you may think they need responding to - Hugh Milne

The more we impose judgement upon the body, the further we move away from the truth. The body is omniscient. What we think is irrelevant. To believe our ego can control the fates is fallacy. The only truth is to Know. The Knowing comes from openness, receptiveness, and humility. The Knowing comes from knowledge. The knowledge comes from reflection. The reflection comes from experience. To err is human. To Know is Divine.