What's the Deal with Cupping and Dry Needling?

Emily: [00:00:00] Hi, Perry. We're here in person.

Perry: [00:00:03] It's so cool to be in person. This is our first in-person episode.

Emily: [00:00:07] Well, it's very nice to see your face.

Perry: [00:00:08] You too. We are in the lovely Yale Broadcasting Center here in New Haven, Connecticut. We have Ryan McAvoy, our Yale side.

Emily: [00:00:16] Thank you.

Perry: [00:00:17] Ryan engineer in the background here, making a sound. Amazing. And of course, Tamar, our ever producer on the other end of the line. So cool.

Emily: [00:00:25] This is so fun. I have a great time.

Perry: [00:00:27] We're talking about cupping and dry needling today. And I came into this knowing deep in my soul one thing being true, and that is that Emily clearly would never do dry needling, because you have mentioned in at least six episodes so far that you're afraid of needles. Yeah. And, and would never like do Botox or anything like that simply because you don't want someone injecting something into you. And then you kind of casually mention offhand like, oh yeah, like I had needles in me that they were putting [00:01:00] electric current through.

Emily: [00:01:02] I have done, I have done this where they stick the needles in and they put like a, like jumper cables on them and they go like to.

Perry: [00:01:09] A.

Emily: [00:01:09] Car battery. Yeah, yeah, yeah. And then and then they get your, your muscle to contract a lot.

Perry: [00:01:14] Um what muscle? Why were you doing this?

Emily: [00:01:16] I was injured.

Perry: [00:01:18] Were they trying to extract information from you?

Emily: [00:01:20] It's like it's it was, it was in the service of recovery.

Perry: [00:01:23] Were you in Eastern Europe?

Emily: [00:01:25] Yeah, I was it was my very, um. I mean, chiropractor who always fixes everything. His name is Dennis. And I don't know, he said that this would fix my problem. And I feel like it did, which is a comment about the rest of the episode.

Perry: [00:01:41] Okay, so I'm starting this episode incredibly surprised. Also hearing that Emily has a chiropractor. I don't know what I'm gonna do with that. I'm gonna take that in as we go into the break.

Emily: [00:01:55] I'm Emily Oster, I'm an economist and a data expert.

Perry: [00:01:59] And I'm Perry Wilson. [00:02:00] I'm a medical doctor.

Emily: [00:02:01] It's Thursday, June 4th, 2026. And this is wellness, actually.

Perry: [00:02:06] Because you're getting a staggering amount of health and wellness information nowadays from every source imaginable. And some of it is awesome.

Emily: [00:02:14] And some of it is, well, actually bullshit. Fortunately, we're both people who know how to read studies, how to parse the data, and can tell you what's worth thinking about and what you can safely ignore.

Perry: [00:02:27] But before we dig in a note that this podcast is for educational purposes and should not be construed as medical advice. We don't know your unique situation, so talk to your doctor for personal health decisions.

Emily: [00:02:39] This week we're asking what's the deal with cupping and dry needling? Perry and I will give the official smash or pass, and then we'll get to your question of the week. But first, let's do the health news roundup after the break. And [00:03:00] now for the health news of the week. Perry, I want to start with some really good news. There was a meeting of the American Society of Clinical Oncology this week, and perhaps the most successful presentation was about a new medication called Direct sun, which is a pancreatic cancer treatment. The results in the survival curve pictures were so spectacular that the author got a 42 second standing ovation. And then.

Perry: [00:03:33] Unbelievable.

Emily: [00:03:34] In the true spirit of people whose time is limited for their presentations, was like, that doesn't count against my time. Uh, so this is incredibly exciting, I will say. I want to hear what you think, but I also want to surface that one of the things that's come up, some in the discussions online amidst the people saying this is amazing is people saying, oh, well, it's only a median survival increase of seven months, you know? Where's my cure for cancer? [00:04:00] And so I'm curious, where's my cure?

Perry: [00:04:02] Yeah. Okay. I mean, first of all, let's level set a little bit here. We're talking about metastatic pancreatic cancer. I mean, one of the worst diagnoses a person can possibly get. The one year survival after diagnosis of metastatic pancreatic cancer is something like 10%. Right. This is a absolutely terrible disease. This new drug is an oral Ras inhibitor. So it's not chemotherapy per se. It's um it's obviously quite powerful, but it targets a mutation that's commonly found in these cancers. And this was a phase three randomized controlled trial of 500 patients with metastatic pancreatic cancer. Pretty big trial in this space. And the difference in median survival was about six months. Associated. You can translate that into a survival rate difference [00:05:00] or hazard ratio of 0.45. So you can think of that like a 55% reduction in the risk of death over time. Um, this is unheard of in this disease. Like it's really, there's, there's nothing that's ever come close to this. Hence the standing ovation at the Asco meeting. But yes, it's it's not a cure. You know it's it's unlikely sadly to say like curing. Absolutely curing any given disease is always a bit of a pipe dream with the exception of rare infectious diseases that only infect humans and can be prevented with vaccines. And even then, we have a great deal of difficulty doing that. People will continue to die of pancreatic cancer because there's a lot of mutations and things that can make different cancers different, but this is obviously a huge improvement over the status quo. I think the other thing that I want to ask you about, because I'm sure you'll have a thought on this, is people looking at the difference in median survival of like, okay, six months [00:06:00] or whatever, and they say, oh, well, but how much are we spending for six months of life? And I know we've talked about this offline. Like, I don't think this is the right way to think about this. Tell me how you think.

Emily: [00:06:09] Yeah, I don't think so. I mean, I think often people hear that and they think, well, if I didn't get the treatment, you would live for three months. And if you got the treatment, you would live for nine months. As if those things are sort of set in stone. But in fact, what this is sort of translating to is at all time points, people are less likely to to die, and they've kind of aggregated that out. But what it means is that you're getting increased survival, you know, potentially for quite a long time.

Perry: [00:06:36] And it's an average.

Emily: [00:06:38] It's an average. And so when we think about like, what would it mean to cure something? Or what would it mean to sort of deliver a lengthy period that would be very meaningful. Some of the people who are treated with this new treatment live, in fact, about half of them were still alive at a year, which is again.

Perry: [00:06:58] Compared to 10%.

Emily: [00:06:59] To [00:07:00] 10%. And, you know, again, some of those people are going to be live longer than that. So you're buying some time on the on the tail. I think the other thing people miss is, okay, this is the first line of this, like, we're going to get better. The side effects are going to presumably be better under control. And it's, you know, opening up new lines for how we would have longer term survival. And if you look at something like metastatic breast cancer, which, you know, has had prior to this, a lot of innovation, the way people are thinking about the potential survival in that disease is very different than they were ten years ago, including to the point of saying maybe people could live ten, 20 years with metastatic breast cancer. So just this.

Perry: [00:07:44] Feels like the same thing, like with metastatic melanoma, which also used to be like, oh, that's a death sentence. And now with immunotherapies and some other therapies, it's like, no, okay, people are living. I mean, take Jimmy Carter, right? A long time with metastatic melanoma. So this is huge progress. It's just we've made a lot unabashedly good news.

Emily: [00:07:59] Exactly. [00:08:00] Very, very good news.

Perry: [00:08:01] We don't usually think about mosquitoes as being good news. But but maybe it is. Google. Yep. Google, the alphabet company that Google wants to release 32 million mosquitoes in Florida and California, presumably so that we all stay inside and use their services more. Absolutely. What's going.

Emily: [00:08:23] On? It's a pitch towards the internet. No. So so the goal here is to release mosquitoes, male mosquitoes that are sterile. And that would then outcompete the non sterile mosquitoes for sexual partners but then be unable to fertilize the eggs due to being sterile, and that that would lower the mosquito population. So it's basically an attempt to control the longer term mosquito population by introducing a bunch of mosquitoes that are shooting blanks in the hopes that you will get fewer later.

Perry: [00:08:58] By the way, a mosquito vasectomy, very difficult [00:09:00] surgery, very delicate, very delicate.

Emily: [00:09:03] Fortunately, they're using other techniques to to achieve this. So this is actually something that has been tried with some success in other settings, particularly in places where malaria is is endemic. This is something people have talked about as a potential approach to eliminating the species of mosquitoes that spread malaria. And we've had some we've had some success with that. The trick here is, of course, you probably don't want to get rid of all of the mosquitoes. And most species of mosquitoes do not cause disease in people. So in the US, there are some diseases you get through mosquitoes like West Nile. You can get triple E which is very bad, but most mosquitoes are just annoying. And they also feed the birds and the frogs and other things that we like. So like completely getting rid of mosquitoes is probably not a good idea, but this isn't a potential approach. You think you're okay with it now, but then there's no frogs and then there's no whatever is bigger.

Perry: [00:09:58] Okay, fine.

Emily: [00:09:59] Listen, Perry, [00:10:00] it's a it's an ecosystem, okay? But getting rid of the mosquitoes that, uh, that give you terrible diseases is something people are interested in. And this is this is one sort of simple approach that is arguably better than spraying them with a bunch of toxins, which we've tried in the past and has some downsides. All right. All right, Perry. There's a new study about farting, and I'd love you to just say more about farting.

Perry: [00:10:27] I, so I wrote about this study this week, and it's of course you did, because of course I did because the study comes out and it's like, oh, this is the greatest advance in metastatic pancreatic cancer in history. And I'm like, but this week I'll be writing about farts. Um, yeah. So here we are. Um, so a new study in Jama Network Open tracking the gaseous emissions of a bit over 6000 Australians as part of a citizen science initiative. They, um, they all volunteered and downloaded an app [00:11:00] called chart your fart.

Emily: [00:11:02] Chart your fart chart your fart guys.

Perry: [00:11:04] And, uh, when you fart, you open the app and you mark the time of day. And you can also optionally, um, like rate it across several scales, including, um, the smell and the audibility. And actually one of the things was the detectability, which is, um, you know, to test whether you smelt it, dealt it, um, the, the actual reason for this study is to generate normative data on how often people fart so that you can have some baseline against which to measure outcomes for gastrointestinal illness trials. So if people are complaining about excessive flatulence, like you need to know what normal is, you can be like, oh yes, that is excessive. So you need to kind of have a normal distribution. That's what the study was for. I was looking into a little bit of the history of studies of farting. Farting. One of the earliest, um, [00:12:00] was from 1781. There was a, a 75 year old scientist who noted that we fart about seven times a day. By the way, the Australian, uh, study said about five times a day, men slightly more than women. But I think women are lying.

Emily: [00:12:15] Um, men are also lying, but fair enough.

Perry: [00:12:17] Okay, it's probably more than that, right? Anyway, back in 1781, seven times a day, according to the scientist. And he wanted to create a prize to invent a substance that could be added to our food that would make, quote, the natural discharges of wind from our bodies, not only inoffensive but agreeable as perfumes, sort of saying like, why can't.

Emily: [00:12:37] We just why can't our farts smell.

Perry: [00:12:39] Better? And yeah, why can't our farts smell better? And, you know, it's been, um, more than whatever, 200, almost 250 years. And we have not, we have not cracked that particular chestnut problem. Do you know who that scientist was in 1781?

Emily: [00:12:56] I do not.

Perry: [00:12:57] Benjamin Franklin.

Emily: [00:12:58] Benjamin Franklin. Okay. That guy had a lot of good [00:13:00] ideas and some less good ideas.

Perry: [00:13:01] And I think he was, like, a little bit of a dirty bird.

Emily: [00:13:04] Okay.

Perry: [00:13:04] Don't you think?

Emily: [00:13:05] I think a little bit. Yeah, they probably all were. Um, the other thing that I thought was interesting from this study is when people fart, they fart at night. So you fart like the majority of.

Perry: [00:13:15] But you're not tracking at night. You mean when.

Emily: [00:13:17] You're like between 6 and 10, between 6 and 10 p.m. after dinner, when people have consumed a larger meal, more fiber? That's when the farts, uh, get going.

Perry: [00:13:25] I mean, that's certainly when my dog is farting the most.

Emily: [00:13:29] No comment on yourself. Okay. All right, that's it for the health news of the week after the break. What's the deal with cupping and dry needling?

Perry: [00:13:42] And we're back. We are going to talk about cupping and dry needling today. This is a two for one episode. We'll start with we'll start with cupping. Smash or pass cupping. Then move on to dry needling. Do the same thing. So I want to start with cupping. And I'm going to play you a clip from a sciencey talking [00:14:00] influencer online. You know, saying like, what is this cupping stuff that people are talking about?

Influencer: [00:14:05] For over 3000 years, cupping was an ancient practice that helped people accelerate their body's healing. The practice was documented in ancient Egypt and China, and it was also endorsed by Hippocrates. And so how cupping works is that it applies a gentle vacuum pressure upon the surface of the skin and tissues. And it's more than just pulling on your skin. Studies have shown that cupping dilates your blood vessels to improve circulation, removes metabolic waste by improving your lymphatic drainage, and supports the local immune function in that area, and past randomized controlled trials show that cupping is an amazing complementary therapy, helping people with chronic lower back or neck pain, fibromyalgia, and even migraines. And even better, cupping helps you fight stress by improving your body's parasympathetic tone and also regulating the stress hormone called cortisol. Key takeaway here is don't judge a book by its cover. Cupping is one of those ancient [00:15:00] practices fused with modern science that shows it accelerates your body's healing.

Perry: [00:15:05] Walk me through what do you think when you hear that off the top?

Emily: [00:15:09] This is ridiculous. It's the same thing, I think when I see. I mean, just like that is my first reaction. Okay. My brother has this done, actually.

Perry: [00:15:15] Oh.

Emily: [00:15:16] All right. And he's always showing up to family vacations with these, like, bruise, not bruises, but these things all over himself.

Perry: [00:15:22] They're bruises.

Emily: [00:15:23] Okay. He's always showing up with all of these things all over himself. And, uh, I always just think think it's ridiculous. And I make fun of him, as one does with one siblings.

Perry: [00:15:32] Yeah. I mean, you should always make fun of your siblings, but we do need to check what the evidence actually shows. I mean, one of the things when our listeners are, are hearing that there are things that often show up in this space that sound legitimate and kind of aren't. One is called the argument from antiquity, which, you know, he said, um, you know, from the over the, for at least 3000 years people have been doing this. Um, and the implicit in that statement is like, well, it must [00:16:00] work if people have been doing it for 3000 years. And of course, there's countless counter-examples of things that people have done for a very long time, like bleeding people for diseases.

Emily: [00:16:11] They had other ideas.

Perry: [00:16:12] You know, crushing witches under large stones and other things that they did for an awfully long time that probably weren't a good idea. So I always kind of, when I hear the argument from antiquity, I kind of roll my eyes. I'm like, all right, but we can do better than that.

Emily: [00:16:24] Yeah, I agree with that. I also, I want to take a step back on both cupping and dry needling, because I think this is a place where we are going to have to engage aggressively with the placebo effect. So we talk about the placebo effect a lot. Just to be clear, the placebo effects refers to the fact that when you do something to someone or have somebody take something or tell them in some way, something might make them better. Even if you did nothing, even if the pill you give them is a sugar pill, even if the cups are not effective and do nothing, you can, you will are still likely to get people to respond because [00:17:00] they think something's going to happen. Yeah. And that is a very, very powerful effect. And this works even better than we think. Um, so one, one piece of this is that placebo effects tend to work better when people believe that they're going to work. So if you believe in something, it's more likely to show up.

Perry: [00:17:19] As.

Emily: [00:17:19] A placebo. Yeah. Uh, the second thing, and this is, I think my most interesting fact about placebo effects is that you can get a placebo effect even if you tell someone it's a placebo. So if you tell someone, I am giving you a sugar pill, but a lot of people find that it helps. Even though there's nothing in this pill, you will get a placebo effect versus telling them, you know, versus not telling them that, right? Like people can get the placebo effect even if they know it's fake. Right. And I think like, that's.

Perry: [00:17:45] It's crazy. The brain is.

Emily: [00:17:46] The.

Perry: [00:17:47] Brain.

Emily: [00:17:47] Is crazy. So interesting. But what that means for this stuff is, or for any kind of any kind of attempt at a causal inference of some treatment is you really need to generate [00:18:00] a placebo feeling in everyone. So if you give people a vaccine, we give everybody a vaccine. We don't just give half the people a vaccine and tell the other people, well, you're in the control group. We give them a vaccine of something else. So they think that they got the vaccine.

Perry: [00:18:13] Yeah. Or yeah, some, some different, some different.

Emily: [00:18:15] We give them a.

Perry: [00:18:16] Placebo or something like that. They have to believe. Yeah.

Emily: [00:18:19] It is very difficult to do that kind of placebo controlled trial with something where the result of the treatment is to end up with giant welts all over yourself because it's like, what is the fake welts? Yeah. Yeah. And it comes up in the needling stuff too. Like it's people have to know that they did this. And we can talk about how, how studies try to control for this. But for me, this whole space is like very wrapped up in the fact that it could just be all the placebo effect or a huge share of it.

Perry: [00:18:46] Yeah. When we talk about the studies, we'll try to flag when studies are, quote, sham controlled, which is the idea being that they do something to you. It's the equivalent of a placebo. But as you're pointing out.

Emily: [00:18:59] This is a case where [00:19:00] that's very.

Perry: [00:19:00] How do you do that? Right. And we'll talk about that and whether it's adequately controlled. The other thing I want to say about placebo effects is that there are certain outcomes that are more amenable to placebo, and some that are less so subjective outcomes, things like pain, pain, mood, energy, fatigue, things that you kind of self-report are quite susceptible to, to placebo effects. You know, things like death, LDL cholesterol, stuff like that.

Emily: [00:19:28] Did you get this infectious disease? Yeah.

Perry: [00:19:31] Those are more objective. And although there are actually some studies that even show placebo effects in those areas, they generally are not as strong as we'll see in this area. And so when you come to to wellness, things like cupping and dry needling, it's like a perfect storm of, okay, is this placebo? Is something biological actually happening? And there's one other whole set of things that we'll hit on here. As long as we're taking a 50,000 foot view before we really dive in. And that's something [00:20:00] called co-intervention bias. So a classic example of co-intervention bias. Let's say I have a new blood pressure drug and I'm going to test it against placebo. So I got a sugar pill and a new blood pressure drug, and I split my group in half and half get the blood pressure drug, half get the placebo. But you know, in the group that gets the blood pressure drug. I call them once a week to check in to see if they're having any side effects. I know the placebo people aren't having side effects. It's a sugar pill, but I'm a little worried. So I'm going to call once a week and be like, hey, like, how are you doing? You feel light headed? What's going on? That interaction is another intervention, a co-intervention that is being applied just to one group. And so when you design these studies, you have to be really careful that you're not testing other things, right? So you actually need to call the placebo group and be like, are you having any side effects? Like you've got to do the whole thing.

Emily: [00:20:47] And then they probably are because that's how the placebo works. Like, yes, actually, I feel my hope is very, I've been farting so much.

Perry: [00:20:54] 100% when it comes to practices like cupping and dry needling and acupuncture and chiropractic [00:21:00] and everything. There's a set of co-interventions that aren't just the cups going on you. You're in a nice dark room. There's like calm music playing. Another human is there and like talking to you and putting their hands on your body. And these in and of themselves can have powerful biologic effects and psychological effects. And so we really have our work cut out for us to try to tease out the unique marginal benefit of adding a cup to this lovely.

Emily: [00:21:27] Lovely other.

Perry: [00:21:28] Quiet room.

Emily: [00:21:29] Yeah. All right, so let's start with for the for the uninitiated, there are basically three kinds of cupping. So please tell me what these are and why you don't want the one called fire.

Perry: [00:21:44] You know you don't want fire cupping.

Emily: [00:21:46] Fire cupping.

Perry: [00:21:47] That sounds awesome. I don't want wet cup. All right, let's start. Okay. Most of the cupping you're going to see online is dry cupping. And what this is, is you it's it is literally a cup, like a suction cup. You put it on a part of your body. You'll see people with it on their back. But [00:22:00] like any place that it'll stick and you suck the air out, typically with a vacuum pump and it sucks the skin up into it. Usually the vacuum is quite strong, in fact, strong enough to break the capillaries under the skin, which causes bleeding under the skin. That's bruising.

Emily: [00:22:14] That's a bruise.

Perry: [00:22:15] That's a bruise. That's what it is. Those cut marks are bruises. That's called dry cupping. Wet cupping is the same thing. But the practitioner nicks the skin, um, before they put the suction cup on. So it actually.

Emily: [00:22:29] Isn't this just bleeding? Isn't this just when we have a thing called bleeding.

Perry: [00:22:32] We're getting.

Speaker 4: [00:22:32] Real close.

Emily: [00:22:33] Real close. It's like we're the leeches. Could you put leeches on and then put the cup on top of the leech? And then.

Perry: [00:22:39] I mean.

Emily: [00:22:39] That would not be good for the leech.

Perry: [00:22:40] I'm sure if we go. Yeah. I don't think the leech likes that, but um but yes, so that's, that's now you're like sucking the blood out a little bit as you're, as you're sucking fire. Cupping is just kind of a cool and more dangerous way of creating the vacuum. So instead of a vacuum pump, what you do is you light a little piece of paper or like a, [00:23:00] I think, use a cotton swab soaked in alcohol, you know, and so you light it, you put it under the, um, under the cup before it's on the person's body. So hot air gets inside and then you stick the cup on the person. And as the hot air cools, it contracts. Right. And that creates the.

Emily: [00:23:16] Size like a low tech. It's just like low lower tech version, lower tech version. Why are people doing this? What is the point of this activity?

Perry: [00:23:27] Here's the argument you see, and I've seen this many, many times. It's like massage is good.

Emily: [00:23:33] I agree with that.

Perry: [00:23:35] But in massage we push on you and it compresses things. And this is like massage, but the opposite, like we pull, it's going to open up your muscles. It's going to like stretch things out and let things kind of flow around and stuff like that.

Emily: [00:23:51] Okay.

Perry: [00:23:52] Yeah.

Emily: [00:23:52] Yeah.

Perry: [00:23:53] What do you.

Emily: [00:23:53] Think? I mean, I think it seems ridiculous, like, but, you know, I guess that's what data is for. I mean, this feels I might [00:24:00] have said the same about massage. And I think we again. Well, we can talk about that in another episode. But but I guess this is a place where I'm not totally clear on the biological plausibility. And I think part of the issue is it's in a lot of these discussions, it's actually not at all clear, like, what is the outcome we're looking at? Right? So it's a lot of these, it's like it's toxins.

Speaker 4: [00:24:21] Oh yeah.

Emily: [00:24:21] We're doing we're going to put this on. It's going to pull out the toxins. Like that's not how. First of all, that's what your kidneys or liver. You have all these organs. Internal organs for dealing with the toxins. But also just like pulling on your skin is not it's not like pulling out. That doesn't make any sense. That's a stupid idea. Really dumb.

Perry: [00:24:38] For toxins. Absolutely. So that's just bullshit. That's straight up bullshit. Nothing is coming out of your skin. Even the wet needling when, like, a little bit of blood is coming out of your skin like blood. It's blood. Your kidneys are going to filter way more blood. I've said this before, but I'll say it again. The kidneys filter 100ml of blood per minute. Right. All day long. That's a lot.

Emily: [00:24:59] It's their whole job.

Perry: [00:24:59] That's [00:25:00] a lot of blood that cycles through your entire blood volume. Like 25 times a day. You're not getting that much out from from wet cupping. And also it's not like it gets cleaned and you.

Emily: [00:25:11] Don't clean it and put it back. It's just like you just lose it and it's like, and how would it know to take out the bad blood anyway, right? Whatever. This is stupid.

Perry: [00:25:18] But okay, so let's just put toxins aside. I want to go to musculoskeletal because I think that's where like the most biologic plausibility is. And one of the videos I saw felt more like massage than the others. So you'll see videos where there's just like cups, cups, cups, cups, cups, like someone's entire back is just lined with these suction cups. And yeah, there, I'm like, that's.

Emily: [00:25:39] What my brother does.

Perry: [00:25:40] That's what your brother does. Okay. And also like Michael Phelps does, right? Like you see athletes that are doing this, etc. then I saw a video where a person took a cup. They had kind of, um, I guess they had like lathered up the skin a little bit so they could make a seal. I think it was on the guy's leg and they were moving the cup up and down the leg. So it was sucking and they were kind of moving [00:26:00] it. And I was like, okay, that's massage with extra stuff.

Emily: [00:26:03] Right? Like it feels a little bit like the arguments for foam rolling or something. Like basically some kind of like fairly aggressive, like muscle interaction that sort of causes some muscle breakdown, which then should come back better, which I think is the idea behind foam rolling. Yeah, I understand.

Perry: [00:26:21] Yeah. Um, you know, I was thinking about massage versus cupping two and like this argument that, oh, massage is compressing and cupping is whatever the opposite of compressing is tensing. But then I was like, actually, you know what? Massage also like stretches like you're not just pushing straight down, right? You're moving, which means like you're obviously you are pulling tissue aside and like letting stuff flow and whatnot.

Emily: [00:26:48] So is this just a kind of massage?

Perry: [00:26:50] I think there are ways to do this, that it's just a kind of massage. And that's probably fine. Like if you're taking the cup and moving it around and not causing the like capillaries [00:27:00] to break in the skin and causing big bruises, then maybe it's just a kind of fancy massage. And if it feels good, that's okay.

Emily: [00:27:09] Do we have any data that would suggest that this is good?

Perry: [00:27:13] Sure. There's always data.

Emily: [00:27:14] There's always data.

Perry: [00:27:15] Yeah.

Emily: [00:27:16] Um, yeah.

Perry: [00:27:17] I want to talk. I think about chronic, non-specific, low back pain.

Emily: [00:27:22] Everybody loves chronic, non-specific, low back pain. I mean, this is like a very common problem that people have.

Perry: [00:27:27] A hugely common problem. And you know, that trope that's like, doctors hate this, okay? That's what.

Emily: [00:27:33] Doctors do.

Perry: [00:27:33] Hate that I hate this. Yeah. And the reason I hate it is because I have no great treatments for chronic, non-specific, low back pain. I mean, I have like physical therapy and exercise and weight loss, but it's just those things are hard for people to do. And, and it goes on and on and on. Okay. So I have a study here from the Journal of Physiotherapy 2021. Um, dry cupping versus sham for chronic non-specific low back pain. We've got 90 people, 45 got dry cupping, [00:28:00] 45 got Sham Sham cupping for four weeks, and they followed up at eight weeks. And both groups had a modest improvement in chronic, non-specific low back pain in the end, including the sham cupping group.

Emily: [00:28:15] Right. And I will say this is. There was no significant difference in that study. And it's actually quite difficult to sham cup someone because just like people know, if you are putting a cup on and sucking things out and they're ending up with like giant bruises, right? Versus just like someone put a cup on you like people. People are not idiots. You know, it's.

Speaker 4: [00:28:34] Like.

Emily: [00:28:35] So unless you're putting the cup on and then like coloring it in or something or like, I don't know, what is the thing you do to make people think that you gave them a somewhat painful bruising? Yes. This is I don't think this is comfortable. It's not, it's not like a no, no, it hurts.

Perry: [00:28:49] It hurts, it hurts absolutely. Like it's really sucking up there.

Emily: [00:28:52] This is an example where I don't even know why. Sham. I mean, I guess you get a little bit of the.

Perry: [00:28:56] You called it sham.

Emily: [00:28:57] You told maybe you told people like maybe if you never had [00:29:00] this before and you had that, maybe that's the case. You never had this before and you don't know. You don't know what to expect, the thing to expect. And so you just think it's someone waving cups around over you. Like maybe then yeah, that's I still, I'm, I mean, and anyway, didn't find anything, so I didn't.

Perry: [00:29:14] Find.

Emily: [00:29:14] Anything. Fine.

Perry: [00:29:16] What they did here just to give him some credit is they, they had special cups that had a little like valve in it. And so it would suck. Like they would put it on and they would apply the suction a guy. And then like a few seconds later, all the air would like leap back in. So you did feel a little bit like and then it would like deflate.

Emily: [00:29:36] So maybe that's why it didn't, it didn't work. This is also not in a very good I mean, a lot of these papers that try to talk about this are actually not in very good journals. And I think that can be hard for people to tease out. Yeah, tease out like, why is the journal of, you know, this? And the more something, the more words are in the title of the journal, the worse it is. It's not always true, but it can be difficult to figure [00:30:00] out is this really something where it got aggressive peer review and some real experts looked at it? Or is it just, you know, you paid the journal $1,000 and they publish your paper, which definitely there are many journals like that.

Perry: [00:30:11] Yeah.

Emily: [00:30:12] Yeah.

Perry: [00:30:12] Absolutely.

Emily: [00:30:13] I guess, I mean, my feeling on this whole space is like, it's very, very unlikely that this has anything but a tiny marginal impact. But if it is something that people like and they feel like it helps them, then maybe that's maybe that's fine. Well, that's where.

Perry: [00:30:38] We always come down with placebo, right?

Emily: [00:30:39] I know it's like if it's just, if it's just.

Speaker 4: [00:30:41] Like.

Perry: [00:30:42] You know, what's the harm? You know, you're spending some money, we'll go through some harms. There are some actually interesting case reports of harms, but I do want to give one more, uh, potential positive for, for cupping, which is in blood flow. Okay. So it would make sense maybe that if you like suction a lot, that like more blood would flow to that [00:31:00] area. And that has been shown with, uh, laser flowmetry, uh, which is a technique to measure blood flow and pretty significant increases in blood flow, like 10 to 15 fold increases. That does sound obviously like a lot like, oh my God, I'm increasing blood flow by 10 to 15 times in this local area of the skin. That's actually pretty similar to what happens if you were to like burn your skin or get a sunburn or any other injury, like your body is pretty good at, um, recognizing when injury happens and directing a lot of blood flow to that area. Um, you know, maybe injuring an area of skin is good, like in the long run, maybe it, you know, I don't know for what. Well, for what um, for, yeah, I got nothing. I don't.

Emily: [00:31:49] Know. I mean, yeah, I think to say like this injures you and then blood goes there to treat the injury. Okay. Sure.

Perry: [00:31:56] Yeah. Where have we gotten our sewer system?

Emily: [00:31:58] Yeah, but I'm not sure. Like, I think we would want [00:32:00] to see the second phase of. Okay. And then you feel better later.

Perry: [00:32:04] Yeah.

Emily: [00:32:05] Which is the part that's that's missing, right.

Perry: [00:32:07] So, um, and when we talk about that injury, the other thing I saw online about cupping is people interpreting the bruising like as if it means something, right? So like, oh, this color bruising means your blood has more toxins and this means less toxins. And, and like you can.

Emily: [00:32:23] It's like if it's green, you're.

Perry: [00:32:25] Yeah, yeah, yeah.

Emily: [00:32:25] If the green, if it's a green bruise, like just forget it.

Perry: [00:32:28] Yeah. Yeah. Or you're a Vulcan. Um. Hello, Tamar.

Emily: [00:32:32] Hello.

Perry: [00:32:32] Um, so so yeah, these are just, these are like, you can do this to yourself. You probably did have a kid, like, sucked on your own.

Emily: [00:32:40] Absolutely. Yeah, totally.

Perry: [00:32:41] Like, gave.

Emily: [00:32:42] Yourself a hickey. These are hickey. A hickey. It's a hickey. Yeah. It's like a it's like an adult. It's like a doctor. Hickey. It's basically. It's a doctor. Yeah. We know.

Perry: [00:32:52] Um. All right. Should we talk about risks?

Emily: [00:32:55] Yeah. There are some risks. Yeah. I think the first thing to say is it was when you cut into your skin, [00:33:00] you could get infected. So something where you cut your skin and then you pull some of the blood out. Like this is always a risk for infection. And so there are cases of infection. And also, just like anytime you're injured, there's any time you cut yourself, there's a risk of infection. And that is part of the reason you shouldn't do that.

Perry: [00:33:17] Yes.

Emily: [00:33:18] Um, you could also burn yourself if there was fire. You can burn yourself with fire and you can get infected if you cut yourself. So, uh.

Perry: [00:33:25] Yeah, let's.

Emily: [00:33:25] Stick.

Perry: [00:33:25] Maybe let's stick with dry cutting.

Emily: [00:33:27] Stick with dry at best.

Perry: [00:33:28] Yeah.

Emily: [00:33:29] Uh, and then there are there you can get a hematoma, which doctor, doctor Perry tells me hematomas.

Perry: [00:33:34] Well, okay, so hematoma is a bruise. But what this type of hematoma is a subdural hematoma, which is a bleed on the outside of your brain. There have been three case reports I found in the literature of subdural hematoma from cupping. These were people who were getting cupping on their necks. So like right at the base of the occipital bone here on the bottom of your skull and your neck for chronic neck pain. There's some very delicate blood vessels [00:34:00] in there that go up into your brain. And, you know, I guess what had happened here is that when they sucked that up, they damaged those blood vessels again. That's what the marks are. It's broken capillaries. But in this case, these would have been veins probably that broke and that bled under the skull and above the brain, which can compress the brain and is generally a bad thing. So you want to be careful.

Emily: [00:34:24] All right. And if it's just bruises, are bruises dangerous?

Perry: [00:34:30] I mean, not really. Although you can get iron deposition, like permanent staining of the skin from the iron in blood if bruises are are bad enough. So there's some aesthetic risk there. Some people who are very prone to scar formation, like keloid formation can get keloids from repeated cupping, which is also, um, you know, aesthetic, but like probably.

Emily: [00:34:53] Not, probably not.

Perry: [00:34:53] Ideal. And certainly if you're talking about wet cupping, right. Scarring.

Emily: [00:34:57] Yes. Scarring. Yeah. Don't cut yourself. Uh, you [00:35:00] could get infection and get a scar. Okay. Perry, are you a smash or pass on the cupping?

Perry: [00:35:04] I am passing on the cupping just to get a massage, folks. Sorry.

Emily: [00:35:08] I am also a strong pass on hot cups and all the cups. All the cups. Hot cups, cold cups. Don't forget it. No. No bruising.

Perry: [00:35:16] But it's okay to be in your cups from time to time. That's an old.

Emily: [00:35:20] Timey way of old timey way of.

Perry: [00:35:21] Saying drunk.

Emily: [00:35:22] I think. Yeah, yeah, we can cut that out. That's from when Perry and I were in college.

Perry: [00:35:30] And people were necking and giving each other.

Emily: [00:35:32] Yeah, that's what we remember. Kids remember hickeys from the 90s. They were.

Perry: [00:35:37] They're coming.

Emily: [00:35:38] Back. They're coming back.

Perry: [00:35:39] On your back. Let's move on to dry needling. So I'm going to show you a video now. There's no audio here, Emily, but I wanted to I just want you to describe what you're seeing. We'll put this on the YouTube. But like for people who are listening audio, just talk me through what you're seeing here.

Emily: [00:35:58] All right. So there's a guy, [00:36:00] he's laying on his face and someone is putting a needle into him. They're pushing it really far into his eye, into his like a shoulder muscle and just moving it up and down like, like a stab with a stabbing motion. It just keeps going. The caption on this thing says, still going, okay. I'm done. Okay, now they're taking it out. I'm done with this video. Yeah, yeah.

Perry: [00:36:23] That's dry needling.

Emily: [00:36:24] Okay. So dry needling. Yes. It's a plate you put. You stick the needle in. It looks actually bit like acupuncture. It looks like quite, quite a bit like acupuncture. But the needle goes much further in and is typically sort of, or at least in some cases kind of moved around. Uh, there are kinds of dry needling that involve electronic stimulation, where you stick in the needles and you hook up.

Perry: [00:36:49] That's what you got.

Emily: [00:36:49] That's what I got. And you hook up a system to it and you run some current through it and it like dit dit dit dit dit dit. The muscles. Yeah. And that is also uncomfortable. Um, and so [00:37:00] yeah, it's a, the idea, I think, is that you are damaging the tissue and that that then promotes healing. This is my general understanding of this is that it is another way to try to, in a targeted manner, like tell your body, come over here and pay attention, fix this up nice. Because it's like we're having some problems with this. Yeah, this area, that's my sense.

Perry: [00:37:26] I think that's the generous interpretation of what's happening here.

Emily: [00:37:31] That's what the chiropractor said.

Perry: [00:37:32] Okay. Um, I want to draw a distinction between wet needling, just like what do we why dry needling? And the answer is that doctors inject substances into you all the time.

Emily: [00:37:44] Sure.

Perry: [00:37:45] And so I don't know if you've ever had a cortisone injection into joints or oddly.

Emily: [00:37:49] No. Oh, okay. Yeah, I'm sure it's coming. It's coming. Talk about it.

Perry: [00:37:52] You know, or lidocaine injections or whatever. And so you have a hollow needle and you stick it in somewhere and you inject. That's a wet injection. [00:38:00] But people, I think, appropriately asked when it came to things like cortisone injections in the knee, they're like, is it the cortisone that we're injecting? Or is it just the fact that we're sticking a needle in there and some of the sham controlled studies of wet injection, which just were like, well, we'll stick a needle in and not do anything.

Emily: [00:38:16] Also works, right?

Perry: [00:38:18] And so either.

Emily: [00:38:19] It's called the placebo effect guys.

Perry: [00:38:22] Either it's a placebo.

Emily: [00:38:24] It's that's what it is.

Perry: [00:38:26] There's something about the needle itself. And so now you have needles that are, I mean, some, some dry needling practitioners will use hollow needles, but oftentimes it's just a solid needle. Like there's not even a, you're not pretending to inject anything. It's.

Emily: [00:38:39] It's that there's another piece of this which you sometimes hear, which is this idea, like we're going to stick it in a muscle. Not so a lot of what people like to use dry needling for is like, you know, releasing trigger points, trigger points. So it's like there's sort of different ways to, to release trigger these [00:39:00] muscle trigger points. But this is like you stick it in. I think it's almost like people have in their mind, like it's literally like a, like a shoelace knot. And if you like got something in there, then it would like release actually didn't work for shoelaces either. But. Right. But I think that if.

Perry: [00:39:14] You look at the AI that people are putting out, there's so much AI on Instagram of like, look what happens. And the needle goes in and like this, like literal knot of a muscle dissolves and it's like, okay, wait, if you're showing AI, then clearly you don't have.

Emily: [00:39:25] Any.

Perry: [00:39:25] Actual good images.

Emily: [00:39:27] Yes.

Perry: [00:39:27] Um, can I, I went on such a deep rabbit hole.

Emily: [00:39:31] Okay.

Perry: [00:39:31] About muscle knots. And I honestly don't know if I'm in a place where my natural social awkwardness is limiting my understanding of this.

Emily: [00:39:40] Okay.

Perry: [00:39:40] Okay. So Trigger points is the medical term. It's associated with something called myofascial pain syndrome, a real syndrome of chronic muscular pain. That seems to be exacerbated there, like certain points in the muscle that are hypersensitive, that are often linked to, you know, what the laypeople would call knots. Like when you're giving someone [00:40:00] a massage and you're like, ooh, there's a knot and I'm working out the knot. Okay. I haven't given many massages in my life. Okay. Or received them.

Emily: [00:40:07] Okay. So so far, it's going. This story is going good.

Perry: [00:40:11] See, I just don't like being touched in that way. Okay. But I will say, when I was like a theater kid in high school and there was just lots of massages going on, people would be like, ooh, you've got such a knot here. And I was like, I don't know that I do. Like, there were tender parts. Like obviously there are parts that hurt more or hurt less. And then when I was massaging people, They'd be like, oh, that's a knot. And like, I didn't know that I ever felt it. I was like, is this is this a collective hallucination that they're actually like physical? Like I felt bones, you know, you can feel like there are bones underneath or like, is there no such thing as muscle knots? Is what I'm asking? Or do I not lack the human contact to understand this?

Emily: [00:40:54] I think they're okay. I don't really know what it would mean. It's not like the muscle tied in a knot. Well, I know that. [00:41:00]

Perry: [00:41:00] I'm saying like, is there a lump?

Emily: [00:41:01] Like, yeah, I feel.

Perry: [00:41:02] Bumps, but I think it's just.

Emily: [00:41:03] Like ribs and stuff, right? Because I, I think it is very clear that like you, if you are doing this even on yourself, like, and you, you, there are places where you can, where I can feel.

Perry: [00:41:15] This is the closest Emily and I have ever gotten to giving each other massages right here where.

Emily: [00:41:22] There's like a knot in my. I think this is a real thing, but I'm not sure what. I think this is a real thing.

Perry: [00:41:29] Okay, I went deep enough in this to look at the imaging.

Emily: [00:41:33] You looked at science. You didn't just you're not just basing your information on like things that happen in my leg last week, which is what I'm basing this on.

Perry: [00:41:41] I was thinking biologically, if you if you circle back to the creatine episode, we were talking about exercising to failure, which which is this idea that muscles can only contract until they run out of ATP. And then they just. Yeah. And you fall down flat on your face. So the idea that there's a knot in my muscle that's like continuously contracting seems biologically [00:42:00] implausible to me. Sure. And so then I looked at like MRI studies and ultrasound studies to see what the imaging correlates of a trigger point would be. So like if, if I, if I using my hands feel a trigger point, like how, what do we see on ultrasound or what do we see on, on ultra on, on MRI? So there was an MRI study. These are small studies. So ten people got an MRI. A practitioner palpated the trigger points and marked them. And then looked for MRI like not blinded, like knowing where the trigger points were. Looked for differences on the MRI scan between, uh, you know, the trigger point and other parts of the muscle. And they found one difference on a very specific type of MRI, uh, spin called MT T2, which had a value that's meaningless to me, but was 33 milliseconds versus 29 [00:43:00] milliseconds.

Emily: [00:43:00] P hacking.

Perry: [00:43:01] To me for normal. So it wasn't like on MRI, like this part of the muscle is bright white and this is black. Like this is pretty subtle. Ultrasound did a little better. Um, nine people with myofascial pain syndrome and a known trigger point. The ultrasound found local areas of reduced vibration amplitude over the trigger point. Like I guess it didn't like it didn't jiggle as much as it should. I literally don't, I'm like, I'm not, I'm not. I'm, I'm just trying to like, chase this data down. Maybe it's hard, but I guess I'm wondering whether the premise of dry needling is that you're putting them in a specific place that matters similar to acupuncture, like you're looking for the trigger point and you're putting the needle there and maybe it doesn't. Maybe you just need to be in the muscle. Full stop.

Emily: [00:43:50] Yeah. I mean, I think that that is my read of, of the dry needling. I find your deep dive on this totally fascinating. I still think there are muscle knots, but that's [00:44:00] it's interesting, but I my sense of, of kind of the, the broader picture of the dry needling is that a lot of it is you have a muscle or something which is sore or like needs attention. And this is a way to like bring more attention to it. And the thing is, there's a million different in the sports space. There's like a million different ways that people think about doing this in an effort to like address sort of sore muscles in particular, not.

Perry: [00:44:29] Just trigger points.

Emily: [00:44:30] Not just trigger points. So things like, I mean, I would put foam rolling in this category. Like, you know, there's a thing called muscle scrape. There's like a, like a muscle scraper and you basically just scrape, scrape, scrape, scrape, scrape on your muscle.

Perry: [00:44:41] Over the top of the skin.

Emily: [00:44:41] Over the top of the top of the skin. And that, and the idea is like it, it like injures it sort of injures it, but then it increases the blood flow. And I think this is the same kind of space, which is different from the idea of I'm sticking a needle in and releasing a trigger point, which feels I agree on.

Perry: [00:45:00] Like, [00:45:00] like maybe.

Emily: [00:45:01] It's.

Perry: [00:45:01] It's not quite like we're, we're finding energy meridians and, but it's close. It's close. Okay.

Emily: [00:45:07] As usual, let's go to the data. Is there any actual evidence that this, uh, that this improves things?

Perry: [00:45:14] Can I give you one more biologically.

Emily: [00:45:15] Plausible.

Perry: [00:45:16] Factor aside from just increasing, like telling your telling your body that there's a problem here is that, um, pain dampens pain. So, um, if you like stub your toe, you might find you'll feel better if you actually, like, rub it. Squeeze it. Right. Or even if you like, rub or squeeze another part of your body. Um, so you can overcome the pain signals. Uh, in part of your body by like engendering further pain.

Emily: [00:45:43] Isn't that just a short term? Like it's pretty short term? This is like, this feels like all these things should be looking for like, I did this and then four days later, I feel better.

Perry: [00:45:51] Yeah, yeah.

Emily: [00:45:51] And that's not that's an hour later, like you're hitting someone on the head and then they're like, oh yeah, my knee doesn't hurt that much. Now that you've hit me in the head with a hammer. It's like, yeah, okay.

Perry: [00:45:58] I guess my point is it's not just [00:46:00] distraction. It literally like the signal doesn't get to your brain, right? Um, okay, let's talk about the data. We got a lot of studies here. I mean, should we do shoulder pain? Because that's what I'm interested in.

Emily: [00:46:12] Let's do shoulder pain. And then we can do we can do knee pain because that's what I'm interested in. And we can do our different old person problems.

Perry: [00:46:20] Um, all right. Talk to me about, Uh, let's see. This is a study from the journal Pain Reports. Pain reports.

Emily: [00:46:29] Exactly 2021 high impact factor journal, which I find is like, all right, so, uh, so, you know, this is a study with active and sham control groups. There's 20 people in each group. All these studies are super, super small. There is a dry needling effect, which is significantly different between the, the active and the sham, uh, and the sham group. It's kind of on the, I would say on the margin of, of significance. [00:47:00] It's not, you know, it's not our most significant thing, but of course, it's a very small study. So, you know, I don't know.

Perry: [00:47:07] Do we believe in sham is I feel like sham dry needling is easier than sham cupping.

Emily: [00:47:14] Because you put the needle in like in a less.

Perry: [00:47:16] Like if you feel a little pinch in your skin, you could convince me that you're doing something right.

Emily: [00:47:21] Yeah, I think it feels easier to do this. And also if you think, I mean, there's actually a pretty good sham acupuncture, for example, which is where you like acupuncture in the wrong places. Now, that's particularly easy because acupuncture is supposed to be about a specific location. Here you have to do it.

Perry: [00:47:37] Generally the sham acupuncture. Uh, studies show that it works as well as acupuncture. Definitely not better than nothing.

Emily: [00:47:45] Better than nothing, but just the same as. Yeah. So yeah, I thought this was interesting. Again, the effects are fairly they're fairly small and they're not like wildly significant and they don't last forever. Yeah. So I don't know.

Perry: [00:47:57] Um, the knee pain study [00:48:00] is quite a bit bigger.

Emily: [00:48:01] It's big.

Perry: [00:48:02] Yeah. So this is coming to you from the Clinical Journal of Pain in 2018. This is a study of 242 participants with knee osteoarthritis. Half of them got six weeks of electrical dry needling like the kind that.

Emily: [00:48:18] The kind that I got. Yeah.

Perry: [00:48:19] Um, and, uh, manual therapy, which is just like massage and stuff like that and exercise. And the other group just got manual therapy and exercise. This had a pretty dramatic effect actually. So in terms of like a significant improvement based on this global rating of change scale, 75% in the dry needling group had a successful outcome compared to 18% in the just manual therapy and exercise group at three months. Of course, the problem here is that it's not there's no sham control here, but still a pretty big effect size.

Emily: [00:48:56] I thought this was an interesting I mean, I think there's an interesting thing here which relates a bit [00:49:00] to your point about co co-intervention, which is like what they're doing here is they're doing this and they're doing exercise and like, they're, they're sort of layering this on top of other things. And so one interpretation of what they find, which I'm not sure in the study, they actually give me enough information to figure this out. But like, if I think that the pain that the dry needling is going to make it more possible for me to exercise, like if this is going to improve my engagement with the exercise, because I think I feel better then you like layer on top of this of the placebo effect. Also the kind of like, well, the exercise is more effective because you're doing it more because you think it's going to work better. And then it's like both more exercise and more needling.

Perry: [00:49:44] Right, right, right kind.

Emily: [00:49:45] Of thing shows up. So I think there's a sort of like a, like an additive placebo additive. And we know exercise is good, right?

Perry: [00:49:52] Well, it's like placebo. We should probably consider this for its own episode, but what's that like kinetic tape that people.

Emily: [00:49:59] Kt tape.

Perry: [00:49:59] Yeah, yeah. [00:50:00] I haven't looked at the data yet, but I'm suspicious that that can do much. Um, but you're right. If just having it makes you feel like I can work out a little harder, maybe work out a little harder, right. And that that actually does make you feel better.

Emily: [00:50:15] So I, that was my, a little bit of my read of this because the effects are very, the effects are very big. I mean, knee pain is known to be very, very susceptible to placebo effects. I mean, some of our very best placebo stuff is in like even knee surgery where like, you can show that, uh, that just cutting someone's knee open and telling them that they were in knee surgery is like basically as good as actual knee surgery.

Perry: [00:50:39] Right, right. Well, what happens after you get fake knee surgery is you get physical therapy, right? Regardless, which.

Emily: [00:50:45] Is probably very good for your.

Perry: [00:50:47] Yeah. Um, so, uh, totally.

Emily: [00:50:50] Yeah. So I mean, again, I think with all of these things, like it's. Ah, is it the placebo? Like, and does it matter? That's always, I always [00:51:00] want to ask that with like, what it like, does it matter if like the thing that that is, if it's not Jane, we can get into harms. But if it doesn't matter if it if there's no real harm.

Perry: [00:51:09] Yeah, we'll talk about harms and there's costs, but also even in a good randomized trial, even with a sham control, what you almost never get is an active comparator control, which is should I like given my, uh, knee pain, should I do dry needling or cupping or physical therapy or aqua therapy? Right. So, you know, it's, it's actually not hard in a lot of the wellness space to find small studies that appear to be decently done that might suggest some benefit of a given intervention. Um, we've talked about publication bias. Like you're probably not seeing all the studies that don't show an effect and all that kind of stuff. Um, but you know, the real question for you is, okay, I've got this problem. What's the best way to fix it? And [00:52:00] some of the I in the end, I often come back to biologic plausibility. Like I want the thing that is the most plausible and has the best data, as opposed to just anything that has data is good enough.

Emily: [00:52:12] I also think this layers your belief about this layers on top of these placebo effects, right? Because in some sense, like the thing you should do if you thought there were a ton of things that were vaguely plausible, but probably a lot of it was driven by placebo effect, you should pick the one you believe in. Oh yeah. Because that's the one where you're going to.

Perry: [00:52:28] Get the best. Your faith is strong enough.

Emily: [00:52:30] Exactly. So it's like if you think dry needling is the thing that works, that's the one you should pick. If you think cupping is the thing that's worked, that's what you pick. If you think you pick the one that you think, I mean, that's how you're getting. That's how you're getting your most effective placebo.

Perry: [00:52:41] Are you saying that people basically should stop listening to this podcast where we're like, I don't know about this and.

Emily: [00:52:46] Just go with.

Perry: [00:52:46] Their gut?

Emily: [00:52:47] Nothing's going with your gut. No, no. It's like, you need to keep listening. So you have support for your gut.

Perry: [00:52:52] Okay.

Emily: [00:52:53] Uh, for your different knee pain problems.

Perry: [00:52:55] But you do have to think about risks. So let's talk about risks of dry [00:53:00] needling.

Emily: [00:53:00] Generally, the risks are fairly small. I mean, again, we sort of talked about cutting yourself and pulling blood out. Here you are sticking. You are sticking needles into yourself. There's, you know, there's bleeding. Uh, you know, major events are pretty rare. There are some pneumothorax which which are more of a problem.

Perry: [00:53:23] So, um, I don't know if you knew this, but TJ what the linebacker from the Pittsburgh Steelers.

Emily: [00:53:30] I don't really follow football other than Taylor Swift. Related football news.

Perry: [00:53:34] Um I think Taylor's okay. In December of last year he got taken to the hospital for like a lung issue. Um, and what it turned out was that he had a pneumothorax from dry needling. Um, and so what a pneumothorax is, is a collapsed lung. And it's actually pretty interesting. So the way the lungs work is that, you know, you've got this diaphragm that sort of moves up and down and [00:54:00] the lungs are in the chest, and there's essentially a vacuum between the outside of the law and the inside of the chest wall. So as the diaphragm goes down, the only place air can go to fill that vacuum is into the lung. There's no path into the inside of the chest wall. Okay. But if you create a path into the inside of the chest wall and your diaphragm goes down, then air goes into the chest instead of in through your mouth and into the lungs. And that has the effect of just collapsing the lung as if it were like a balloon.

Emily: [00:54:34] It's like a popped a balloon.

Perry: [00:54:36] It pops.

Emily: [00:54:36] A balloon.

Perry: [00:54:36] Balloon. And we get quite scared about this in medicine. Sure. Because we do stick, a.

Emily: [00:54:44] Lot of you are using your lungs all the time.

Perry: [00:54:46] People need them, it turns out. And we stick a lot of needles in this area, particularly in people who are pretty sick. Like we'll put in a central venous catheter, for example, in the internal jugular vein, which is, you know, right here. For those of you listening, I'm just like pointing to [00:55:00] my neck. But the top of the lung, the top of the pleura is pretty darn close, and we'll use ultrasound and stuff to make sure that we're not violating that space. Because then you get a pneumothorax.

Emily: [00:55:11] Which you can fix, but you have to you can fix, you have to reinflate the lung.

Perry: [00:55:15] I have had this complication. Really? Yeah.

Emily: [00:55:18] Like on yourself?

Perry: [00:55:19] No. No.

Emily: [00:55:20] No.

Perry: [00:55:21] Fortunately, on someone I was trying to.

Emily: [00:55:22] Take care of. No.

Perry: [00:55:24] Much worse.

Emily: [00:55:25] Um, I was dry needling myself, and I just.

Perry: [00:55:27] Know I was. I was putting a central line in the ICU in this, uh, this guy. Very skinny, very little tissue above his lungs. To give myself a little bit of a defense here. And, you know, this is a known complication. We consent people. We tell them that this is something that could happen. And we always get an X-ray right after we put in one of these lines to make sure there's no pneumothorax. And it's like 3 a.m. in the ICU, and I get the X-ray and it comes up and I'm like, oh, you know, and I had to call. It's embarrassing because you have to call surgery and like, I'm a medical doctor and I'm like, hi guys, you know.

Emily: [00:55:58] Can you.

Perry: [00:55:59] Can you fix my problem? [00:56:00] And they come and they put in a chest tube and it's fine, but it's not great. And so what happened to TJ? What is? He was getting dry needling in the trapezius muscle right here in your neck. And you just go too deep. You hit the lung. That's kind of there was a report of this of a case series of 17 serious complications from dry needling. And 15 of the 17 were pneumothorax. So your lungs are closer to the surface than you think. You really do have to be careful about this.

Emily: [00:56:26] So a little more careful if you're doing it up in your neck. Yeah. You smash or pass on dry needling. Perry.

Perry: [00:56:34] I'm I you know, I've never had it done. Uh, I am a I'm a pass on this again. I, I don't think it's worth the potential risks. I still think getting a nice massage in a quiet, dark room with some nice music playing is going to make you feel good. Emily, you had this done. It made you feel better.

Emily: [00:56:54] Yeah. Smash your smash. I'm a smash. Uh, I'm a smash if you believe in it. And I, I will [00:57:00] say I, I based on my experience, I believe in. And so if I, if I had a similar related injury, I would probably do it again. Yeah.

Perry: [00:57:11] All right. All right. That is it for.

Emily: [00:57:13] But not in my neck. Not in my neck.

Perry: [00:57:16] Maybe not your back or anywhere where.

Emily: [00:57:18] Just your legs in my. I would do it in my legs. Probably smashing the legs. Not otherwise.

Perry: [00:57:23] That's it for cupping and dry needling your mailbag. Question of the week after the break.

Mailbag: [00:57:33] Hi, Emily and Perry. This is Delilah from Detroit. Settle a bet between my partner and me, please. She says that it's best to brush your teeth when you first wake up in the morning. I say it's best to wait until after breakfast. Who's right? Thanks so much.

Emily: [00:57:51] It turns out the best time to brush your teeth is before breakfast, particularly if you're going to have coffee. I think most people brush their [00:58:00] teeth after breakfast. But actually, food starts to like the acid in your food can like affect the enamel. And so then when you brush your teeth after breakfast, you like remove more of the enamel than if you brush your teeth before breakfast. And so I actually think that the dentist recommended thing, since of course, you don't also want to have food in your mouth. Like when you eat breakfast and food gets in your teeth. And then that's also bad. Yeah. Is you should brush your teeth like when you wake up. And then after breakfast, you should rinse your mouth with one of those like water flosser things to get the food out from between your teeth.

Perry: [00:58:33] Okay.

Emily: [00:58:34] Yeah, I don't do this, but I think this is the, the.

Perry: [00:58:38] I.

Emily: [00:58:38] Am recommended thing.

Perry: [00:58:39] I'm definitely like, a coffee is gonna stain my teeth and therefore I should brush my teeth after I have coffee. But, but maybe I should just rinse.

Emily: [00:58:45] Out my mouth. Yeah. Maybe you should rinse out your mouth. Yeah. I will say I am my dentist, like least favorite client because I don't really believe in routine. Like I think we over exaggerate people. I'm not afraid of X-rays, [00:59:00] but I generally think like routine dental X-rays are unnecessary and I don't have dental insurance. And so it's both a belief about routine dental X-rays based on some data and also a feeling.

Perry: [00:59:11] About the economics of.

Emily: [00:59:13] Money. And so I'm, I'm like always on the edge of like just how they will they insist that you have routine X-rays some number of years to stay in our dental practice, which I like very much, but every time I'm trying to push them off. So like I've been pushing them off and off and off. And finally last time they were like, if you don't do it next time, we're not going to see you anymore.

Perry: [00:59:31] Oh my God. It's like getting kicked out of a practice like a, like someone, you know, refusing vaccines.

Emily: [00:59:36] Yeah, exactly. I'm like, I'm like the anti-vaxxer of this dental practice. And, and I feel a little bad about it. And my husband's always like, I like this dentist, like, don't get us kicked out. Like, don't get us kicked out by being a weirdo. Like just get the X-rays. So anyway, brush your teeth before breakfast, kids.

Perry: [00:59:53] From your teeth to God's ears.

Emily: [00:59:58] That's it for us today. Stick with us next week [01:00:00] when we'll ask, what's the deal with Hypoactive sexual desire disorder? Oh, I'm I'm. I'm interested to discuss that.

Perry: [01:00:08] Okay. Let's go.

Emily: [01:00:13] Well, this actually is produced in association with iHeartMedia. Our senior producer is Tamar Avishai. Our executive producer at iHeart is Jennifer Bassett. Our theme music is by Eric Deutsch, and our content is for educational purposes only.

Perry: [01:00:27] If you like the show, help other people find us. Leave a rating and review on Apple Podcasts or your podcatcher of choice and help us spread the word about the show. You can follow us on Instagram at podcast. And don't forget, we want to hear from you. Head over to wellness.fm and leave us a question for our mailbag or suggest a topic for a future show.

Emily: [01:00:49] We'll let the influencers have the last word.

Influencer 1: [01:00:51] What is this thing?

Influencer 2: [01:00:52] So, you know, like cupping?

Influencer 1: [01:00:54] Yeah.

Influencer 2: [01:00:55] Like people do it with like fire and stuff. Like they have digital ones and it's much easier. So it vibrates, it heats [01:01:00] up. It's got red light.

Influencer 1: [01:01:02] Let's see.

Influencer 2: [01:01:02] Yeah. It's like like that. Yeah.

Influencer 1: [01:01:04] Ooh. Look at oh my gosh. Do you see how much that is pulling at his skin. Wait. I thought you had to go to a spa for one of these.

Influencer 2: [01:01:16] No, it feels good. Oh, yeah.

Influencer 1: [01:01:18] Does it feel good. Is it getting your not.

Influencer 2: [01:01:20] It's finally. Yeah. It's. And the nice thing is, you know, it's like it's in one spot. So now it's actually like getting that spot. Usually I roll on a ball.

Influencer 1: [01:01:27] But wait, how long do I leave this on for?

Influencer 2: [01:01:29] Just as long as until it's done with its session.

Influencer 1: [01:01:32] Can I take it off?

Influencer 2: [01:01:33] Yeah. I mean, you could.

Influencer 1: [01:01:34] I want to see. Oh.

Influencer 2: [01:01:37] Yeah. I've got a mark.