What's the deal with cupping and dry needling?

23:32Emily Oster:Yeah, some different drug or a saline placebo or something like that. They have to believe. Yeah. It is very difficult to do that kind of placebo control 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. You know? Yeah. And it comes up in the needling stuff too. Like, people have to know that they did this. And we can talk about 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.

24:05Emily Oster: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. This is a case where that's very. 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, mood, energy, fatigue, things that you kind of self-report are quite susceptible to placebo effects.

24:43You know, things like death, LDL, cholesterol, stuff like that. Did you get this infectious disease? Yeah.

24:51Emily Oster: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 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 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.

25:28Emily Oster: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 you doing? You feel lightheaded? 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?

26:02Emily Oster:So you actually need to call the placebo group and be like, are you having any side effect? Like you've got to do the whole thing. And then they probably are. Because that's how the placebo works. Yes, exactly. Actually, I feel my poop is very – I've been farting so much. A hundred percent. When it comes to practices like cupping and dry needling and acupuncture and chiropractic 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.

26:32Emily Oster: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, you know, adding a cup to this lovely, quiet room. All right. So let's start with 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. You don't want fire cupping? You don't want fire cupping? That sounds awesome. I don't want wet cupping. All right, let's start. Okay, most of the cupping you're going to see online is dry cupping.

27:12Emily Oster:And what this is, 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 like any place that it will stick. and you suck the air out, typically with a little 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. That's a bruise. That's a bruise. That's what it is. Those cup marks are bruises. That's called dry cupping. Wet cupping is the same thing, but the practitioner nicks the skin before they put the suction cup on.

27:46Emily Oster:So it actually... Isn't this just bleeding? Isn't this just, don't we have a thing called bleeding? We're getting real close now. We're 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... I mean... That would not be good for the leech. I'm sure if we go... Yeah, I don't think the leech likes that. But yeah, so that's... Now you're like sucking the blood out a little bit 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 – I think it's a cotton swab soaked in alcohol.

28:21Emily Oster:So you light it. You put it 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 – It's like a low-tech. It's just like – Lower-tech version. Lower-tech version. Why are people doing this? What is the point of this activity? Here's the argument you see. And I've seen this many, many times. It's like massage is good. I agree with that. But in massage, we push on you. Okay. And it compresses things. And this is like massage, but the opposite. Like we pull. It's going to open up your muscles.

29:03Emily Oster:It's going to like stretch things out and let things kind of flow around and stuff like that. Okay. Yeah. Yeah. What do you think? I mean, I think it seems ridiculous. But, you know, I guess that's what data is for. I mean, this feels – I might have said the same about massage. And I think we – again, well, we can talk about that in another episode. 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 toxins.

29:40Emily Oster:Oh, yeah. 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 are. Liver, you have all these organs, internal organs for dealing with the toxins. But also just like pulling on your skin is not like pulling out. That doesn't make any sense. It's a stupid idea. It's really dumb. 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. It's blood. It's blood. Your kidneys are going to filter way more blood.

30:10Emily Oster:I've said this before, but I'll say it again. The kidneys filter 100 milliliters of blood per minute all day long. That's a lot. That's their whole job. That's a lot of blood. That cycles through your entire blood volume like 25 times a day. You're not getting that much out from wet cupping. And also, it's not like it gets cleaned and given back to you. You don't clean it and put it back. It's just like you just lose it. And how would it know to take out the bad blood anyway? Right. Whatever. This is stupid. 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.

30:46And one of the videos I saw felt more like massage than the others.

30:50Emily Oster: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 what my brother does. That's what your brother does. Okay. And also like Michael Phelps does, right? Like you see athletes that are doing this, et cetera. Then I saw a video where a person took a cup. They had kind of – 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 it.

31:19Emily Oster:And I was like, OK, that's massage with extra steps, right? It feels a little bit like the arguments for foam rolling or something. Like basically some kind of like a 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. Yeah. You know, I was thinking about massage versus cupping too 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.

31:57Emily Oster: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. So is this just a kind of massage? 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 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 OK. Do we have any data that would suggest that this is good? Sure. There's always data. There's always data.

32:35Emily Oster:Yeah. Yeah. I want to talk, I think, about chronic nonspecific low back pain. Everybody loves chronic nonspecific low back pain. I mean – This is like a very common problem that people have. A hugely common problem. And you know that trope that's like doctors hate this. Okay? Doctors do hate that. I hate this. Yeah. And the reason I hate it is because I have no great treatments for chronic nonspecific 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 it goes on and on and on. OK, so I have a study here from the Journal of Physiotherapy 2021, dry cupping versus sham for chronic nonspecific low back pain.

33:16Emily Oster:We've got 90 people, 45 got dry cupping, 45 got 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. 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 versus just like someone put a cup on you. Like people are not idiots, you know? It's like, so unless you're putting the cup on and then like coloring it in or something.

33:57I don't know what is the thing you do to make people think that you gave them a somewhat painful bruising. I don't think this is comfortable. It's not like a funsy. It hurts.

34:09Emily Oster:It hurts. Absolutely. Like it's really sucking up there. So this is an example where I don't even know why sham, I mean, I guess you get a little bit of the placebo. You called it sham, but we don't buy it. You told it. Maybe you told people, like maybe if you had never had this before and you had, maybe that's the case. You've never had this before and you don't know. You don't know what to expect. That's the thing to expect. And so you just think it's someone waving cups around over you. Like maybe then that's still – I mean, and anyway, it didn't find anything. So I guess it was a fine sham.

34:35Emily Oster:What they did here, just to give them some credit, is 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 to the 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 deflate. Maybe that's why 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 aren't actually not in very good journals. And I think that can be hard for people to tease out. Like why is the journal of this – the more words are in the title of the journal, the worse it is.

35:15It's not always true. But it can be difficult to figure 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 a thousand dollars and they published your paper, which definitely there are many journals like that.

35:31Emily Oster:Yeah. Yeah, absolutely. 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 fine. Well, that's where we always come down with placebo, right? I know. It's like if it's just – 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 potential positive 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 area.

36:19Emily Oster:And that has been shown with laser flowometry, 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 burn your skin or get a sunburn or any other injury. Your body is pretty good at recognizing when injury happens and directing a lot of blood flow to that area. 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 know I mean yeah I think to say like this injures you and then blood goes there to treat the injury okay sure yeah where we got in ourselves super system yeah but I'm not sure like I think we would want to see the second phase of okay and then you feel better later yeah which is the part that's that's missing right 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 this color bruising means your blood has more toxins and this means less toxins and and stuff and like you can enter it's like if it's green you're if the green if it's a green bruise like just forget it yeah yeah or you're a vulcan um hello tomorrow hello um so uh so yeah these are just these are like you can do this to yourself you probably did we ever can like suck down your absolutely yeah totally like gave yourself until you get a hickey these are hickeys about a hickey it's a hickey yeah it's like a it's like an adult it's like a doctor hickey basically it's a doctor yeah it's a doctor hickey um all right should we talk about risks yeah there are some risks yeah i think the first thing to say is it is when you cut into your skin, you could get infected.

38:21So 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, anytime you cut yourself, there's a risk of infection. And that is part of the reason you shouldn't do that. Yes. 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 maybe let's not do that.

38:45Emily Oster:Let's stick with dry cupping at best. And then there are – you can get a hematoma, which Dr. Perry tells me a hematoma is. Well, OK. So a 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. And there are some very delicate blood vessels in there that go up into your brain.

39:21Emily Oster: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 do want to be careful. All right. And if it's just bruises, are bruises dangerous? I mean, not really, although you can get iron deposit, like permanent staining of the skin from the iron and blood if bruises are bad enough. So there's some aesthetic risk there.

40:01Emily Oster:Some people who are very prone to scar formation, like keloid formation, can get keloids from repeated cupping, which is also, you know, aesthetic, but like probably not. Probably not ideal. Great. And certainly if you're talking about wet cupping, scarring. Yes, scarring. Yeah. Don't cut yourself. You can get infection. You can get a scar. Okay. Perry, are you a smash or pass on the cupping? I am passing on the cupping. Just get a massage, folks. It's all right. I am also a strong pass on hot cups and all the cups. All the cups. High cups, cold cups. No, forget it. No bruising. But it's okay to be in your cups from time to time.

40:39That's an old-timey way of saying drunk, I think. Yeah. Yeah. We can cut that out. That's from when Perry and I were in college.

40:49Emily Oster:And people were necking and giving each other hickeys. Yeah, that's when we – remember kids? Remember hickeys from the 90s? They were great. They're coming back. They're coming back. 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 in audio, just talk me through what you're seeing here. All right. So there's a guy. He's laying on his face, and someone is putting a needle into him. They're pushing it really far into his – aha – into his like shoulder muscle and just moving it up and down like a stab with a stabbing motion.

41:34It just keeps going. The caption on this thing says still going. OK, I'm done. OK, now they're taking it out. I'm done with this video. Yeah.

41:41Emily Oster:Yeah. That's dry needling. Okay. So dry needling, yes, is a plate you stick the needle in. It looks actually a bit like acupuncture. Looks like it. 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. There are kinds of dry needling that involve electronic stimulation where you stick in the needles and you hook up. That's what you got. That's what I got. And you hook up a system to it and you like run some current through it and it like the muscles. And that is also uncomfortable. And so, yeah, it's the idea, I think, is that you are damaging the tissue and that that then promotes healing.

42:29This 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 fix this up nice because it's like we're having some problems with this area. That's my sense.

42:46Emily Oster:I think that's the generous interpretation of what's happening here. That's what the chiropractor said. Okay. No. I want to draw a distinction between wet needling, just like why dry needling? And the answer is that doctors inject substances into you all the time. Sure. And so I don't know if you've ever had like a cortisone injection into joints or – Oddly no. Oh, OK. Yeah. I'm sure it's coming. It's coming. Talk about it when I do. 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. 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?

43:29Emily Oster: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, also worked. Also showed effects, right. And so either – That's called the placebo effect, guys. Either it's a placebo. That's what it is. Or there's something about the needle itself. And so now you have needles that are – I mean some dry needling practitioners will use hollow needles, but oftentimes it's just a solid needle. Like there's not even – you're not pretending to inject anything. 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 knot.

44:08So a lot of what people like to use dry needling for is like releasing – Trigger points. Trigger points. So it's like there's sort of different ways to release these 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 shoelace knot. And if you like got something in there, the knot would like really essentially didn't work for shoelaces either. But I think that's the idea.

44:33Emily Oster:But if you look at the AI that people are putting up, 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 good images. Any actual images of this. Yes. I went on such a deep rabbit hole 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. Okay. 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.

45:11Emily Oster:There are like certain points in the muscle that are hypersensitive that are often linked to, you know, what the lay people would call knots. Like when you're giving someone a massage and you're like, oh, there's a knot and I'm working out the knot. OK. I haven't given many massages in my life. OK. Or received them. OK. So so far, the story is going good. I just don't like being touched in that way. 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.

45:49Emily Oster: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 a collective hallucination that there are 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? I think there. OK, I don't really know what it would mean. It's not like the muscle tied in a knot. Well, I know that.

46:19Emily Oster:I'm saying like, is there a lump? Like, yeah, I feel bumps, but I think it's just like ribs and stuff. Because 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 this is the closest emily and i have ever gotten to giving each other massages right here where there's like a knot in my i i think this is a real thing but i'm not sure what i think this is a real thing okay i went deep enough in this to look at the image of science you're just you're not just basing your information on And like things that happened in my leg last week, which is what I'm basing this on.

47:00Emily Oster:Well, because I was thinking biologically, if you circle back to the creatine episode, we were talking about exercising to failure, which is this idea that like muscles can only contract until they run out of ATP and then they just, 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 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 I, using my hands, feel a trigger point, like what do we see on ultrasound or what do we see on MRI?

47:41Emily Oster:So there was an MRI study. These are small studies. So 10 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, you know, the trigger point and other parts of the muscle. And they found one difference on a very specific type of MRI spin called MTRPT2, which had a value that's meaningless to me, but was 33 milliseconds versus 29 milliseconds for normal. So it wasn't like, ooh, on MRI, like this part of the muscle is bright white and this is black.

48:27Emily Oster:Like this is pretty subtle. Ultrasound did a little better. 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 just trying to like chase this data down. Maybe it's hard. But I guess I'm wondering 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.

49:04Emily Oster:And maybe it doesn't – maybe you just need to be in the muscle full stop. 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 much time. But that's 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.

49:49So not just trigger points. Not just trigger points. So things like – I mean I would put foam rolling in this category. Like there's a thing called muscle scrape. There's like a muscle scraper. And you basically just like scrape, scrape, scrape, scrape, scrape on your muscle. Over the top of the skin. Over the top of the skin. And the idea is like it 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, unlikely to be.

50:19Emily Oster:Yeah, like maybe – it's not quite like we're finding energy meridians. Right, but it's close. It's close. Okay. As usual, let's go to the data. is there any actual evidence that this uh that this improves things can i give you one more biologically plausible 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. So you can overcome the pain signals in part of your body by like engendering further pain.

51:03Emily Oster:Isn't that just a short term? 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. Yeah, yeah, yeah, yeah. And that's not because 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 hit me in the head with a hammer. It's like, yeah, okay. I guess my point is it's not just distraction. It literally like the signal doesn't get to your brain. Okay. So let's talk about the data. We got a lot of studies here. I mean, should we do shoulder pain?

51:30Emily Oster:Because that's what I'm interested in. Let's do shoulder pain. And then we can do knee pain because that's what I'm interested in. We can do our different old person problems. All right. Talk to me about – let's see. This is a study from the journal – Pain Reports. Pain Reports. Not exactly. 2021. High Impact Factor Journal, which we'll find is like – We'll take it. 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 active and the sham and the sham group.

52:15It's kind of on the, I would say, on the margin of significance. significance 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 do we believe in sham is i feel like sham dry needling is easier than sham cupping because you put the needle in like you know less like if you feel

52:36Emily Oster:a little pinch in your skin you could convince me that you're doing something right yeah i think it feels easier to do this and also if you think i mean there's actually 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 generally. Generally the sham acupuncture studies show that it works as well as regular acupuncture. That's definitely what it shows. But better than nothing. Better than nothing, but just the same as, yeah. So yeah, I thought this was interesting.

53:09Again, the effects are fairly, they're fairly small and they're not like wildly significant. They don't last like forever. Yeah. So I don't know.

53:17Emily Oster:The knee pain study is quite a bit bigger. It's big. 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 you got. And manual therapy, which is just like, you know, 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.

54:08Emily Oster:Of course, the problem here is that it's not, there's no sham control here, but still a pretty big effect size. I thought this was an interesting, I mean, I think there's an interesting thing here which relates a bit to your point about co-intervention, which is like what they're doing here is they're doing this and they're doing exercise and 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.

54:46Like 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 that kind of shows up. So I think there's a sort of like an additive placebo.

55:09Emily Oster:And we know exercise is good. Right. Well, it's like – Not just placebo. We should probably consider this for its own episode. But what's that like kinetic tape that people – KT tape, yeah. Yeah. I haven't looked at the data yet, but I'm suspicious that that can do much. 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? Right. And that actually does make you feel better. So that was a little bit of my read of this because the effects are very big. I mean, knee pain is known to be very, very susceptible to placebo effects.

55:46I mean, some of our very best placebo stuff is in like even knee surgery where like you can show 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.

55:59Emily Oster:Right, right. Well, what happens after you get fake knee surgery is you get physical therapy, right? Regardless. Which is probably very good for your – yeah. Totally. Yeah. So, I mean, again, I think with all of these things, like it's – is it the placebo? Like – and does it matter? That's always – I always want to ask that. Like does it matter? Well, it matters. If like the thing that is – if it's not, we can get into harms. But if it doesn't matter, if there's no real harm – 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 knee pain, should I do dry needling or cupping or physical therapy or aqua therapy?

56:52Emily Oster: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. We've talked about publication bias, like you're probably not seeing all the studies that, you know, don't show an effect and all that kind of stuff. But, you know, the real question for you is, OK, I've got this problem. What's the best way to fix it? And 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.

57:31I 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, yeah, yeah. Because that's the one where you're going to get the best placebo effect. Yeah, if your faith is strong enough. 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 should pick.

57:55If you think like you pick the one that you think, I mean, that's how you're getting your most effective placebo.

58:01Emily Oster:So are you saying that people basically should stop listening to this podcast where we're like, I don't know about this. And just go with their gut. Nothing's going to work. Go with your gut. No, no. It's like you need to keep listening so you have support for your gut. Okay. For your different knee pain problems. But you do have to think about risks. So let's talk about risks of dry needling. Generally, the risks are fairly small. I mean, again, we sort of talked about cutting yourself and pulling blood out. Here you are sticking needles into yourself. There's bleeding. Major events are pretty rare.

58:36There are some pneumothorax risks, which are more of a problem.

58:42Emily Oster:So I don't know if you knew this, but TJ Watt, the linebacker from the Pittsburgh Steelers. I don't really follow football other than Taylor Swift, related football news. I think Taylor's OK. In December of last year, he got taken to the hospital for like a lung issue. And what it turned out was that he had a pneumothorax from dry needling. 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 the lungs are in the chest. And there's essentially a vacuum between the outside of the lung and the inside of the chest wall.

59:27Emily Oster: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 inside 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. It's like it pops a balloon. It pops a balloon. It pops a balloon. And we get quite scared about this in medicine. Sure. Because we do stick a lot of – You are using your lungs all the time. People need them, it turns out.

1:00:06Emily Oster: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 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. Which you can fix, but you have to re-inflate. You have to re-inflate the lung. I have had this complication. Really? Yep. Like on yourself?

1:00:38Emily Oster:No. No. Fortunately, on someone I was trying to take care of. Much worse. I was dry needling myself. No, I was putting a central line in the ICU in 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 an onomothorax. 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.

1:01:17Emily Oster:Can you fix my problem? And they come and they put in a chest tube and it's fine, but it's not great. And so what happened to T.J. Watt is he was getting dry needling in the trapezius muscle right here in your neck. If you just go too deep, you hit the lung. And there was a report 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. So a little more careful if you're doing it up in your neck. Yeah. You smash or pass on dry needling, Perry? You know, I've never had it done.

1:01:56Emily Oster:I am a I'm a pass on this again 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 yeah I'm a smash I'm a smash I'm a smash if you believe in it and I I will say I based on my experience I believe in it and so if I if I had a similar related injury, I would probably do it again. Yeah. All right. All right. That is it for - But not in my neck. Not in my neck. Maybe not your back or anywhere where - Just more legs. I would do it in my legs.

1:02:40I'm smashing the legs, not otherwise.

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1:04:53Emily Oster: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. 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 teeth after breakfast. Yeah. 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.

1:05:34And 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 it gets in your teeth and then that's also bad, is you should brush your teeth like when you wake up. And then after breakfast, you should like rinse your mouth with one of those like water flosser things to get the food out from between your teeth.

1:05:53Emily Oster:Okay. Yeah, I don't do this, but I think this is the recommended thing. I'm definitely like coffee is going to stain my teeth and therefore I should brush my teeth after I have coffee. But maybe I should just like rinse out of my mouth. Yeah, maybe you should just rinse out of your mouth. Yeah. I will say I am my dentist's like least favorite client because I don't really believe in routine – like I think we over x-ray people. I'm not afraid of x-rays, 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 about the economics of money.

1:06:33And 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. Oh, my God.

1:06:52Emily Oster:It's like getting kicked out of a practice like someone refusing vaccines or something at the pediatrician. I'm like the anti-vaxxer of this dental practice, 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. Don't mess it up for us. 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. From your teeth to God's ears. That's it for us today. Stick with us next week when we'll ask, what's the deal with hypoactive sexual desire disorder? Oh, I'm interested to discuss that.

1:07:27Emily Oster:Okay. Let's go.

1:07:32Wellness Actually is produced in association with iHeart Media. 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.

1:07:47Emily Oster: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 wellnessactuallypod. And don't forget, we want to hear from you. Head over to wellnessactually.fm and leave us a question for our mailbag. Or suggest a topic for a future show. We'll let the influencers have the last word. What is this thing? You know like cupping? Yeah. Like people do it with like fire and stuff like that. have digital one and it's much easier so it vibrates it's got red light let's see yeah look at oh my gosh do you see how much that is pulling at a skin wait i thought you had to go to a spa for one of these oh it feels good oh yeah does it feel good is it getting your knot it's finally yeah and the nice thing is you know knots like it's in one spot so now it's actually getting that spot.

1:08:46Emily Oster:Usually I roll on a ball, but that... Wait, how long do I leave this on for? Just as long until it's done with its session. Can I take it off? Yeah, I mean, you could. I want to see. Oh! Yeah, I've got to mark that.

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