Is the “cupping” of Olympic athletes so awful?

August 10, 2016 • 9:30 am

All over the skeptical/rational blogosphere, people are calling out those Olympic athletes, including Michael Phelps, who have tried to improve their performance via “cupping therapy“: putting small glass bells over parts of the body and creating a vacuum in them that breaks blood vessels below the skin, producing a circular bruise.   Here’s Michael Phelps getting cupped at the Olympics:

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And in action, with his bruises clearly visible:


Many athletes seem to be using this technique:

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(From the Guardian) US gymnast Alexander Naddour at Rio 2016, evidently another fan of cupping. Photograph: Alex Livesey/Getty Images

In principle, this ancient therapy seems unlikely to have any salutary effect on physiology, as all it does is break capillaries, but, as the New York Times reports, there’s some suggestive evidence that it can still be beneficial:

While there’s no question that many athletes, coaches and trainers believe in the treatment, there’s not much science to determine whether cupping offers a real physiological benefit or whether the athletes simply are enjoying a placebo effect.

One 2012 study of 61 people with chronic neck pain compared cupping to a technique called progressive muscle relaxation, or P.M.R., during which a patient deliberately tenses his muscles and then focuses on relaxing them. Half the patients used cupping while the other half used P.M.R. Both patient groups reported similar reductions in pain after 12 weeks of treatment. Notably, the patients who had used cupping scored higher on measurements of well-being and felt less pain when pressure was applied to the area. Even so, the researchers noted that more study is needed to determine the potential benefits of cupping.

Another experiment involving 40 patients who suffered from knee arthritis found that people who underwent cupping reported less pain after four months compared to arthritis sufferers in a control group who were not treated. But the cupped group knew they were being treated — it’s not easy to blind people about whether a suction cup is being attached to their leg or not — and so the benefits might have been due primarily to a placebo effect.

And indeed, if there are effects on athletes, they probably are placebo effects. But placebo effects are real; we don’t know how they work, but simply the idea that you’re being treated can improve many things, including depression.

In fact, “active” placebos: drugs that give you a physiological “side effect” but don’t treat the condition, are even better than “passive” placebos that have no effect you can perceive. That is, depressed patients given atropine, whose effects you can perceive, don’t do appreciably worse than traditional antidepressant medication, and both do better than patients given “passive” placebos like sugar pills. Patients given no treatment do worst of all. There was even one experiment (no longer considered ethical) showing that patients who had “sham” knee surgery, i.e., who were cut into but not really operated on, had outcomes as good as those of patients with real knee surgery.

It is unethical for doctors to prescribe placebos, but I find that regrettable, though wholly understandable and the ethical thing to do, for prescribing placebos involves deceiving the patient.

Phelps and his fellow athletes aren’t being deceived by anyone but themselves, but so what? Lots of athletes have superstitious practices: using lucky bats in baseball games, making the sign of the cross before games or after goals, wearing “lucky” clothing, and so on. That kind of stuff hurts no one. Making the cross, “Tebowing” after a touchdown, and so on are no less harmful, for they validate religious superstition in the public eye. “Cupping”, as a performance enhancer, is unlikely to catch on as a substitute for genuine medicine given for an illness.

In fact, I bet many of us have such superstitious practices. I have a lucky number, which I won’t reveal, and many readers probably have objects they consider “lucky”. This, like cupping, is a harmless superstition. In fact, “proper” cupping, because of the placebo effect, may be far more useful than that rabbit’s foot.

The problem, of course, is “improper” cupping: cupping that isn’t done by experts on pampered athletes. Over at Respectful Insolence, Orac points out some of the dangers, as in this man in China who tried cupping to help a form of arthritis, and wound up with what look like third-degree burns:


Cupping, then, can go horribly wrong. The problem with celebrities doing it in public is not that they look like dupes, but that they might encourage others to do the same. Not everyone who tries it will end up with trendy bruises and a positive outlook. The public, then, needs to know what can go wrong before they opt for such treatment. That is the responsibility of the press rather than the athletes, who are surely ignorant of the problems. And the New York Times article fails in its responsibility here, even quoting Keenan Robinson, Phelps’s personal trainer:
“We know that science says it isn’t detrimental,” Mr. Robinson said. “We know that science says it does in some cases help out. So we’re at least going to expose the athletes to it years out so they can at least get a routine into it.”
Yeah, “not detrimental” when practiced as it is on Phelps. The Times should have at least mentioned possible dangers.

Still much of the vociferous calling out of Olympic cupping doesn’t highlight its dangers so much as constitute a form of virtue signaling: “See, I’m smarter than that stupid Michael Phelps.” In fact, one blogger has even said this about the cupping Olympic athletes: “these people are idiots.” Ignoring the fact that that statement is “ableist”, violating the website’s own norms, I’d hardly call them idiots, any more than I’m an idiot for having a lucky number. There may be small moieties of a person’s behavior that are irrational, but does that make them total “idiots”? Not in my eyes.

Michael Phelps is not an “idiot”, and if he feels more confident after cupping, he could even be called savvy. Whether or not this practice increases woo among the public is yet to be seen.

But if Phelps got homeopathic treatment for cancer, I’d be much more likely to criticize him.

I’ll finish by saying that the placebo effect has been demonstrated many times (and sometimes not), but appears to be a real phenomenon for some conditions. How it works is a great mystery, for inducing the belief that you’re being treated can somehow translate into both subjective and objective perception of improvement. I’d love to see more work on the phenomenon, but much of it is rightly viewed as unethical.

UPDATE: I’ve just read Hemant’s report on cupping at The Friendly Atheist, and he, too, calls it out as worthless, but fails to mention the possible dangers except for wasting money on useless treatments.  He also mentions, as I did, athletic superstitions:

They’ll wear special socks during big games, refuse to shave their beards during the playoffs, go through a certain ritual during warm-ups, etc. Yes, it gives them confidence. It’s be foolish, however, to think their actions have any real, tangible effect.

But that’s wrong. A placebo effect is a “real tangible effect.”

112 thoughts on “Is the “cupping” of Olympic athletes so awful?

  1. I don’t get it. Wouldn’t your criticize an athlete (or anyone) for using homeopathic “remedies”? How is this different?

    1. It isn’t different. Jerry’s simply saying that people are entitled to do whatever they think makes them feel better; and given what little we do know about the placebo effect, this could very well make Phelps feel better. Therefore, he’s not an “idiot”. Uninformed perhaps, but not deserving of abuse.

      If he starts to use his celebrity to promote and endorse the treatment without warning the public of the dangers and that it is unsupported by science as a treatment for anything; then it would be a different story.

      1. The problem with Phelps doing this is that it legitimizes woo, with consequences that can be seen on the back of that guy from China.

        Sure, he’s entitled to do this to himself. Maybe he feels better about himself for having done it, I don’t know. But it seems to me incumbent on those of us who know the difference to point out that woo is woo, even if the participants are sports heroes.

  2. I don’t know. On the one hand it demonstrates the kind of credulity I feel I have to constantly battle. I live with a Chinese family and all the harmless beliefs really take their toll on my relations with them sometimes. The dietary superstitions are by far the worst because then my diet gets restricted by proxy. I can’t cook this or that because such and such is bad or can’t be combined or will lead to instant fatness or prevents digestion or whatever… good grief it’s maddening.

    “How do you know Judy? How do you know it doesn’t work?” – in regards to cupping. All I can say is that I rely on scientific conclusions rather than the word of an athlete, even one who swears by it. Am I virtue signaling? Maybe. Probably. I wish just a little bit of trust in science could be instilled in them. It’s so frustrating.

    1. Balancing the “hot” and the “cold” — I learned this from Chinese friends who were always trying to tell me what was wrong with me based on Chinese medicine. It really is annoying sometimes. Most of them are used to me saying, “that’s bullshit, come on!” Or “That’s voodoo!” Good thing I have good natured Chinese friends.

      1. Yes, both the “magical” hot and cold and physically hot and cold things they don’t like to mix. It’s got a few thousand years’ worth of testing to back it up, so it must be right, right? Turns out the placebo effect hasn’t changed at all throughout the ages.

    1. HA! that’s a great point! and
      i’d be willing to bet there would be a line around the block, hell, the city, to give Phelps that teen version.

  3. Call me old-fashioned, but I prefer to come by my hickeys the authentic, non-mechanical way.

    On the plus side, “cupping” at least sounds kinda dirty.

  4. It should be pointed out that it has been shown that, while placebo effects can produce a subjective feeling of well being, they produce no objective physiologic effects. Also, cupping is based upon a prescientific vitalistic notion of life.

    The problem is not specifically gullible athletes, but that the press tends to swallow this stuff hook, line, and sinker, and present it in quite a gullible way that encourages people to pursue it.

    There are excellent treatments of this topic at the following sites this week:

    1. First, see below for a citation from Harvard Medical school nothing that there are measurable physiological effects on stuff like heart rate, blood pressure, and so on. Where is everybody getting the idea that placebo effects are all purely in the brain and don’t translate into measurable physiological changes? That’s just wrong. Here’s another reference to a WaPo article, with links, showing measurable physiological effects:

      What is a subjective change in well being (or objective assessments in some cases) except a change in something about the body’s physiology, even if that be in the neurons? SOMETHING has to change if there’s a statistically significant effect and proper controls, and, of course, what’s in your mind comes from what’s going on in your brain.

      I agree, though, that the press is remiss in this. But so are some bloggers, I think. Because for something like properly done innocuous cupping, what’s the difference between that and wearing lucky socks? Not much–certainly not enough to call everyone an idiot. What needs to be pointed out is that ther’s no measurable physiological effects (though I’d bet that in some cases of placebo effect there certainly are), and that there are dangers to the procedure.

      1. One significant difference between cupping and wearing “lucky socks” is that we no longer live in a culture which takes magic talismans seriously — but we do live in a society which consistently blurs the distinction between pseudoscience and science. When news stories report as news the solemn and ancient wisdom of remedies based on vitalism and Eastern versions of anatomy, it does more than validate placebos. It validates an entire spiritual system and the type of thinking which validates that.

        What’s the harm of Young Earth Creationism if the belief helps the believer? On a case by case basis, maybe nothing.

        1. When news stories report as news the solemn and ancient wisdom of remedies based on vitalism and Eastern versions of anatomy, it does more than validate placebos. It validates an entire spiritual system and the type of thinking which validates that.

          I was thinking along the same lines when I learned that cupping goes way back in China. Basically, the people who came up with this “treatment” are the same ones driving tigers and rhinos to extinction because they think their body parts have magical properties.

          Why not just get a massage like a normal person in the 21st century?

        2. Yes, I agree. There is a bigger issue with putting pseudo-science on par with real science so that treatments based on pseudo-science and treatments based on science seem to be a choice between two equal options. It may be innocuous to believe cupping works or to believe in astrology, but it becomes problematic when those beliefs become belief systems. That’s when you get people believing in Suzanne Somer’s cancer cures or that we are all going to die because of some Mayan prophecy concerning planetary alignment.

        3. +1
          The danger in otherwise harmless crap like cupping is that these practices are typically part of a larger set of claims that reject evidence-based methods of evaluating efficacy. It is very much like the “package deal” set of beliefs that evangelicals accept vis a vis evolution, politics, global warming, etc.

          1. “It is very much like the “package deal” set of beliefs that evangelicals accept vis a vis evolution, politics, global warming, etc.”

            Exactly! It’s another form of alternative medicine, and any credibility it gains adds to the credibility of alternative medicine as a whole. Alternative medicine that is dangerous, harmful, and even deadly.

      2. Another difference between cupping and lucky socks is that lucky socks don’t leave bruises. You can see the damage he is doing to his body. Why would you want to cause tissue damage and internal bleeding right before an athletic event? Maybe the psychological gain outweighs the physical harm, but I still think it’s idiotic to do cupping before an athletic competition.

        1. On two occasions, I have been offered dubious technniques to help with depression, with the therapist admitting that there was little solid evidence behind it but they had patients who said it had helped. When I said I wasn’t interested I was told “I don’t know what to do. I am offering to help you and you don’t want it”.

          At some point, someone will go to a physical therapist and be offered cupping on the basis that Olympic athletes swear by it.

          1. Oops. That was supposed to be a separate comment which is why it seems a bit of a non sequitur to the preceeding one!

      3. Here is one of the more recent, better references:

        N Engl J Med 2011; 365:119-126July 14, 2011DOI: 10.1056/NEJMoa1103319

      4. what’s the difference between that and wearing lucky socks?

        Lucky socks don’t cost as much as cupping and they also function as socks.

        Having said that, the effectiveness of placebo depends on many things such as the perceived elaborateness of the procedure (e.g. an injection of a neutral saline solution is more effective than a sugar pill) and the cost. Something that looks like it costs more has a better placebo effect than something that is obviously cheap.

  5. One can make cupping seem like a reasonable but mild and temporary treatment for pain by various causes. I have no idea if either of these are in fact b.s.
    a. Swelling caused by local accumulation of fluid in interstitial tissue causes pressure, and this is one source of pain. Swelling is reversed by increased blood flow since circulating blood drains interstitial fluid. Cupping causes an increase in local blood flow, so it can relieve swelling and pain. Reducing swelling is also beneficial for athletes since it increases mobility.
    b. Overworked muscles ache because of micro-tears in muscle tissue. The process of healing the tears requires blood circulation, and cupping increases blood flow.

  6. Placebo effects are self-reported improvements and not independently verifiable improved functioning. That doesn’t make the placebo’s effect ‘real’ in the sense the effect is causally linked to the placebo; the effect is linked to the self-reporting belief that it’s causal. This belief is identical to superstitious belief… a belief that can also cause various physiological responses. That doesn’t make the superstition belief to be true any more than it makes the placebo effect to be true. That’s why it’s woo.

    1. Sorry pal, but I’m afraid you don’t know what you’re talking about. There are independent test of placebo effects on measureable conditions like hypertension, so it’s not “all the mind.”

      Do some research first, okay? Here’s one you could have found immediately, and from Harvard Medical School:

      The placebo effect is for real

      Recent research on the placebo effect only confirms how powerful it can be — and that the benefits of a placebo treatment aren’t just “all in your head.” Measureable physiological changes can be observed in those taking a placebo, similar to those observed among people taking effective medications. In particular, blood pressure, heart rate, and blood test results have been shown to improve among subsets of research subjects who responded to a placebo.

      Of course, not everyone has a therapeutic response to a placebo. If that were the case, we wouldn’t need medications at all. Instead, we could simply wield the power of suggestion. Understanding why certain people improve with placebo treatment and others do not is the “holy grail” of placebo research.

      1. Jerry, you’re jumping the gun here (or you just sort of scanned my comment). I never said it was all in the mind, but clarified that the physiological responses are not linked to the placebo itself (or nocebo, for that matter) but to the belief in their efficacy. This is the understanding I have earned from reading Dr. Steve Novella over at NeuroLogica Blog from whom I have taken my understanding. Now, my understanding might be incorrect but nothing you’ve offered here furthers this.

        1. Heart rate and blood pressure are subject to psychological effects. If you see a new doctor, for example, you are more likely to have elevated blood pressure and heart rate. To say that placebos “work” for those things really does not mean anything. It’ll have the same effect as going back to the doctor a few times and feeling more relaxed in that setting.

          The other issue with placebos is ethics. In order for a patient to have a placebo response, the doctor must lie to the patient about the efficacy of the placebo because the patient must believe that the placebo is effective. That is a line that should not be crossed.

          1. I agree with you about the ethics of prescribing placebos, and apparently so does Jerry (“It is unethical for doctors to prescribe placebos […] for prescribing placebos involves deceiving the patient.”). It’s perhaps worth examining why we feel this is unethical. I take it to be because we regard patients as autonomous agents with the right to make informed choices about their treatment, and deceiving them undermines that autonomy.

            But this seems an odd position to take for a hard determinist like Jerry, who argues that neither rights nor agents nor choices actually exist. So I’m curious to know how he squares his stance on placebo ethics with his view of criminal offenders as meat robots to be reprogrammed by whatever means proves effective.

          2. “The other issue with placebos is ethics. In order for a patient to have a placebo response, the doctor must lie to the patient about the efficacy of the placebo because the patient must believe that the placebo is effective. That is a line that should not be crossed”.

            If that rule is rigidly applied then it is impossible to do drug trials which involve the use of placebos as experimental controls. Of course, properly conducted trials should be “double-blind” so neither the physician nor the patient know if the dose being administered to any given patient is the drug or the placebo so that might get the physician of this particular hook. Nevertheless the phsician knows that she/he is lying to some of the patients even if it is not clear which ones!

            1. In the case of a randomized clinical trial, you are not lying to the patients. They are explicitly told that they may or may not receive the actual treatment, and nobody will know which patients got the placebo until the end of the trial when it is unblinded.

              This is very different than telling someone that an inert substance is effective in treating their condition.

            2. Drug trials are rarely done with the control group receiving a placebo. That would be seriously unethical. Could you imagine testing a new treatment for leukaemia and giving half the patients effectively no treatment whatsoever? You’d be condemning them to death.

              Drug trials are done by giving the control group the current best available treatment and comparing the outcomes with the new treatment.

  7. One element which is consistently part of the placebo effect is that the one receiving it believes that it will work. This aspect surfaces frequently in human interactions: trust that God knows best or parents/government/teachers have your best interests at heart or a merchant will give you a fair deal, etc. However, as with anything, there’s a dark side, and that’s gullibility. There are bad actors who have no conscience who exploit this human characteristic, and sometimes so egregiously, that psychological/physical trauma results.

    There are doctors who use the placebo effect ethically in that they say that though the treatment has no significant statistical efficacy, the doctor still believes it will benefit the patient.

  8. The athletes could be trying other things (and using scientific methods to get actual data) while advancing science and their sport rather than wasting time and resources on something that doesn’t work.

    1. But there’s a possibility that it does work, even if it’s only the placebo effect. And it’s not very time-consuming, either–like a massage. They’re already busy full time with practicing.

      What makes you say that cupping doesn’t work at all in helping performance?

      1. It may very well work, but I don’t think that’s even the issue. Seems to me it’s medical accomodationalism. Giving credence to a practice that is associated with pseudoscience.

      2. “What makes you say that cupping doesn’t work at all in helping performance?”

        An individuals belief that cupping works might help performance, but there is no evidence, or good reason to believe that cupping does.

        1. The point is that it is implausible that cupping “works” beyond a placebo (i.e, a psychological) effect because it is based upon the concept of qi, a universal life force for which there is no evidence.

          That, by itself, is sufficient grounds to reflect cupping.

  9. For those that want to look trendy without going through the actual procedure I’m sure that someone will come up with cupping tattoos.

  10. In Russia this used to be a widely prescribed therapy for bronchitis and pneumonia. Basically, whenever you have a “deep dry cough”. I had it multiple times a year as a kid, and I used to do it to my wife and son. It’s pretty easy actually. The theory was that it increases the blood flow to the affected internal organs.

  11. I think such things can make the brain to put in blood circulation anti-inflammatory substances. In the past a stronger nerve pain had cured middle elbow pain that I had for months, in a matter of minutes and once for all. The question is how you can make your brain to cure you in some situations when is clearly possible? Some things can activate the correct brain reactions. Why my brain needed a much stronger pain to fix a chronic lower pain inflammation?

  12. My concern about this particular deal, as with tattooing and other (specifically wide – area) assaults on the human integument – barrier, is infection. With ones such as the MRSAs no longer sensitive to good, ol’ – fashioned penicillins, well, so too, will Streptococcus (agalactiae) go that resistant way … … and in short order. Especially if broken capillaries and other pummels upon the circulatory, musculoskeletal and neuromuscular systems occur without sound medical inputs and controls.

    This thinking, overall, comes to my mind with re to bloods, uteri and other muscles and resistant antibiotics: withIN my lifetime, my granddaughters and my great – granddaughters will suffer and die from puerperal / childbed fevers — as once did throughout all of ancient times and up through until ~1942, (when, then, a newly formulated thing termed penicillin and cross – continents’ flights xtwo saved the life of my own septically attacked father [a wee slice into one channeling finger, actually, its infectious conduit]) our grandmothers and great – grandmothers.


  13. I was recently in a dilemma about placebo type affect remedies. A co-worker’s son (only 17) has been diagnosed with untreatable brain cancer. It’s a nasty type that spreads all over the brain so you can’t operate on it & it doesn’t respond to radiation or chemotherapy. He opted for alternative treatments that are really expensive. The treatments seem to help his son, which I attribute to placebo affect but at the same time I’m annoyed that these people who treat him are bulking him of his money — couldn’t they compassionately provide their fake cures at an affordable price. To afford the treatments, he set up a Go Fund Me account. I didn’t know if I should donate because didn’t that just say that I approved of this?

    In the end, I decided to donate money. I figured the mental well being of the family was more important than my ethical issues but I still am worried about 1) the bilking by charlatans 2) the family thinks he will beat the cancer (I attribute this to the stories of miracles propagated by the religious and possibly from these charlatans) and I’ve seen first hand how shocked people are when their loved ones go down hill all of a sudden when they haven’t accepted that things will not get better for them.

    So, that was my mental process…..I think it has some relevance here.

    1. My husband used to donate money to the mission-trips taken by the children of a family friend. His reasoning was that he was supporting the child, and the missions seemed more focused on helping the needy than proselytizing. I respected that — but couldn’t think it ethical myself. There are always personal quandaries like that.

      A friend of mine practices a form of faith healing based on New Thought. If you stop believing you’re sick, your sickness will no longer manifest in the material plane, etc. One of her client-friends had cancer, and eventually went from several years of daily calls and correspondence to … nothing. Cut communication off completely. My friend was hurt. But I suspect she did much more damage to the poor client-friend, who must have finally realized Mind Cure doesn’t really work. I don’t know details re what she advised or discouraged, and am afraid to ask, but I really hope my friend the faith healer isn’t guilty of manslaughter.

  14. One thing I guess we know – Phelps didn’t need this cupping to get his first 18 or 19 gold metals. Now he has more. Cupping or no cupping. Also, if we look to the Olympic authorities to put forth an opinion on this, we probably won’t get it. They couldn’t decide whether the Russia’s should be there.

  15. Magical thinking (alternative medicine, mysticism, theology, etc.) can provide relief for a variety of ills through well described physiological mechanisms.

    Placebo controlled trials of new therapies are an important part of science-based medicine precisely because placebo effects exist – physiologic responses that are not bound to any real therapeutic regiment. Placebo effects are measured to establish the true baseline or zero value of a therapy by identifying that portion of the responses in an experimental group that has no causal relationship to any specific therapy. Presumably any inert substance or intervention can cause these effects if properly administered or conducted.

    So the question becomes whether it is permissible to sell substances or services that by their very nature at best generate placebo effects if anything at all, or is it desirable to grant an international seal of approval to these practices that cannot possibly work as their proponents claim at venues like the Olympics.

    Part of the harm is that it further muddies the waters in the public mind about the nature and importance of true cause and effect.

  16. As an aside…

    One of my GGGrandfathers died after having been “cupped”. It was a treatment offered at the time (near the end of the American Civil War). He had been discharged from the Union Army for what they called “pulmonary consumption”. Three years later he was still alive but died following receiving cupping treatment. I doubt the cupping killed him, but whatever placebo effect may have occurred, it wasn’t enough. Happily he had his children before this happened or I wouldn’t be here to type about it.

  17. Now that this practice is widely seen in the Olympics, and especially practiced the medal machine of M. Phelps, I expect it is going to be really really common.

  18. Isn’t religion just an “active placebo”?

    People spend time and other resources performing rituals, many of which have been demonstrated to have no practical and measurable affect on the real world. However, if the placebo effect produces a net positive for the individual’s well being then by all means, have at it. For those of us who are not influenced by the illusion or have had the illusion shattered, the placebo effect is not there and the resources can be put to other uses.

    Of course I’m sure there are people who aren’t actually convinced, but since all the other athletes are doing it, and they don’t want to be seen as outsiders… seem familiar. It’s the Tinkerbell Effect.

    But soon there will be sectarian cupping: “Left upper arm cupping is blasphemous! Murder all left upper arm cuppers!” Well…

    1. Sure, because there are many people who believe placebos work as such. We have a bit of a recursive effect here 🙂

  19. Edzard Ernst is the first professor of Complementary and Alternative Medicine… he has studied scientifically several of alternative therapies.

    The key messages is:

    – “A further problem with clinical trails of cupping is that it is difficult, if not impossible, to control for the significant placebo effects that this treatment undoubtedly generates. There is no placebo that could mimic all the features of real cupping in clinical trials; and there is no easy way to blind either the patient or the therapist.”

    – “The answer is probably more complex than you expect. It clearly has a significant placebo effect. Athletes are obviously very focussed on their body, and they are therefore the ideal placebo-responders.”

    – He pointed out that many CAM trials come from China and they usually do not report adverse events. These and other trials from other countries are of poor quality.

    The first point above I think is the most important one. It deals with the difficulties to perform a great trial of CAM therapy. Very few people really want to discuss these issue and they just want to say the CAM therapy works.

  20. Jerry says: “But placebo effects are real; we don’t know how they work, but simply the idea that you’re being treated can improve many things, including depression.”

    No they are not real. By definition, a placebo effect is an effect which is a consequence of thinking there is an effect when there is no effect of the method of treatment itself. As such, it is unrelated to the actual method of treatment, only to its psychologically expected effect.

    Placebo is very difficult to interpret in case of depression because depression is the kind of disorder in which when a patient thinks he is doing better he is _actually_ doing better. Unlike with cancer – unlike with most other diseases, actually.

    1. I’m not going to argue the semantics about whether an effect is “real” or not. In my book it’s “real” because it’s a consequence of having taken the pill, regardless of whether the pill’s effect is mediated through the brain or directly through effects on physiology without any mental construct necessary.

      You’re simply making up a definition of “real” that wouldn’t correspond with what many people would think of as “real.”

      1. “In my book it’s “real” because it’s a consequence of having taken the pill, regardless of whether the pill’s effect is mediated through the brain or directly through effects on physiology without any mental construct necessary.”

        By that reasoning God is real, since it doesn’t matter whether the effects of God’s existence are manifested by the effects of belief “mediated through the brain” or whether God god actually exists as an independent entity.

        I believe you are being inconsistent.

      2. No, it is not about semantics.

        Placebo is unethical because it is based on a deception – including self-deception and recursive deception. Yes, thus form of deception does have a measurable physiological effect. Is it OK to tout it or sell it because of that? I don’t think so.

        Just as Scote said, it is a problem of inconsistency. Saying cupping is not that bad for this particular purpose is exactly equivalent to saying homeopathy would not be that bad for this particular purpose. (Homeopathy is just as good a placebo as cupping – if you think cupping is better, them you imply it is not only placebo, for which you need evidence that doesn’t exist). And as a scientist, I do not think homeopathy should not be advertised like this or touted as “not so bad” for any purpose. For consistency, cupping shouldn’t be treated with any more leniency than homeopathy, either.

  21. How can one have a “lucky number”, and *knowing it for a superstition* at the same time?

    I have trouble wrapping my head around that.

    1. As Niels Bohr once said about the “lucky” horseshoe above his doorway. “Of course I don’t believe in it, but I understand it brings you luck, whether you believe in it or not.”

      1. Which atheist mathematician was it who jokingly announced he had proven Fermat’s conjecture before embarking on a transatlantic, reasoning that god, disliking him for his atheism, would not let his ship sink lest he enter history as a tragic figure, rather than come safely ashore and admit to having been joking?

  22. I would be interested in the thoughts of folks here on the other visible “alternative” medical practice of the Olympics, kinesio taping. Seems particularly popular with the beach volleyball players, specifically Kerry Walsh Jennings. I recall a lot of athletes using it in the last summer Olympics, but it seems to have faded away except for Jennings and one of the male beach volleyball players that I have seen so far.

    1. Kinesio taping occurred to me as a comparison to cupping as well, and quite a few distance runners I know still use KT. There were some cyclists in the Tour de France who used it as well. I asked a former student (now a primary care physician, and with a sports medicine fellowship completed) about KT, and he thinks it’s harmless woo. In some descriptions I’ve seen, KT is related to principles of lymphatic drainage, which is part of osteopathic medicine.

      Related to your mention of Kerry Walsh Jennings, I heard a description of a “day in the life” of a beach volleyball athlete on NBC the other night (it might have been Walsh Jennings, in fact). Leisurely breakfast, walk through the beach volleyball venue, watch some videos of other athletes, restful nap, more food, massage, blah blah blah. That would be a welcome vacation schedule in my world. I’d be thrilled if someone would prepare just one healthy meal for me in a day, and if I could get more than 5 hours of sleep.

      1. I know dancers who use kinesio taping to help recover from injuries, and their explanation (if I’ve understood it right) is that the tactile sensation of the tape promotes awareness and proper care of the injured area during workouts.

        1. Given that explanation, which is not actually in accord with the wooishness behind Kinesio taping, any kind of tape or elastic wrap or similar would have the same effect.

          1. To be sure, dancers use all manner of tapes and wraps, up and including duct tape, for various supportive and therapeutic purposes. But the impression I have (perhaps mistaken) is that some tapes are used specifically for their particular tactility.

  23. A person who lived in the same boarding house I did did that… I didn’t know what had happened to her, but assumed it was either TCM or she had hugged an octopus. It could have been both.

  24. To deny the placebo effect may be inconsistent with the science, rather than elevating the denouncer to a more rational position. Jerry cites some supportive papers of its effect, and there are more.

    For instance, one meta-analysis found that four sugar pills are better than two (for ulcer healing rates, in this case)[Moerman DE. ‘General medical effectiveness and human biology: placebo effects in the treatment of ulcer disease].

    Another study found that patients with no sign of any concrete medical diagnosis were more likely to recover within a two week period if they were given a firm diagnosis and confidently told they would get better (64%) than being told by a doctor that she cannot be certain of what the matter is with the patient (39%)[Thomas KB. ‘General practice consultations: is there any point in being positive?’].

    The foregoing suggests that an individual’s belief about an intervention may impact upon outcome. Once this point is accepted, I don’t believe that it necessarily follows that those taking part are idiots. In the run up to what is for some sports the biggest competition, athletes will have falls in confidence levels in their desperation to perform well for their country. Their trainer, to whom they pay much attention, might suggest this ‘cupping’ intervention in order to improve performance. The athlete goes along with it (indeed having an open mind about their trainers advice might in part account for their success), at which point the placebo effect might kick in, through, for instance, increasing confidence. Performance in the next training session improves, reinforcing the effect.

    However, I do also agree with Jerry’s point regarding the media’s responsibility to report the possible dangers of cupping. If I wrote for a paper I would be tempted to go further too, and promote the scientific placebo explanation over any magical properties of this technique.

  25. The problem with cupping isn’t that it makes athletes feel better, it’s that it takes science and medicine three steps backwards. Athletes practising cupping is like medical centers offering ‘ancient’ Chinese medicine, and politicians arguing against vaccination, and people diagnosed with cancer choosing alternative medicine. In all these instances people are choosing to act on feeling rather than reason, and that’s very dangerous. Everyone who’s a science advocate should be appaled by this kind of prescientific nonsense. Yes, cupping doesn’t normal harm anyone, but since it has no benefit, the risk:benefit ratio is unacceptably high. Why can’t we have athletes who are willing to act like reasonable 21st century inhabitants and go have a massage instead? It has the same effect, but doesn’t make you look like a duped mothball.

    1. I forgot to mention: that THE thing that people are upset about is the false balance and poor reporting that’s followed from this. Sure, let athletes cup and ingest ground-up tiger and whatever makes them feel better, but let’s also ridicule them for these beliefs. They are just like religion — which is often ridiculed at this site — you don’t need to pit an evolutionary biologist against a creationist for balance before declaring that evolution is true. Cupping is nonsense. A theatrical placebo, as (I think Orac) calls it. It’s a waste of time, energy and money. Like dancing for rain in Texas. Or praying to God for rain.

        1. If I’m not mistaken, the placebo effect mostly comes down to the human connection. Take acupuncture as an example (the original ‘theatrical placebo): it has repeatedly been shown not to work, but it still makes people feel better. And this feeling better is all due to the placebo effect. However, you get a similar effect from doing sham acupuncture, so what’s responsible for the therapeutic effect is the expectation that it’s going to work, coupled with the fact that someone is doing something.

          Praying for an unwell friend is still something, although I chose the examples you refute just to make a point: I find it a bit surprising that people who ridicule religion and don’t really have any ‘belief in belief’ would be so inconsistent to still have ‘belief in alternative medicine’. It’s not the much different. Religion makes people feel better about themselves, and alternative medicine makes people feel physiologically better from placebo effects. But the underlying logic is the same; that the feeling better is a product of prescientific beliefs that even if they do nothing to help, have a real risk of harm.

        2. “dancing or praying for rain doesn’t have a placebo effect.”

          How do we know that? I imagine that these behaviors have some effect on the participants. Not rain, of course, but there’s no evidence that cupping makes athletes swim faster, either. In both cases the participant asserts a benefit. In neither case is there any evidence for beneficial results. In both cases the “what’s the harm?” argument is equally valid (or invalid).

          I don’t see a difference.

        3. It sort of does have a placebo effect if it rains, at least on those who believed in the prayer or dance. And sooner or later it almost always rains, and they almost always attribute their dance or prayer to the rain. No matter how long it is after the prayer or dance.

          By placebo effect, I mean those involved feel better about themselves, and it reinforces their belief that rain dances and praying for rain works. Even if it’s four months later.

          Just like the prayer for rain in Texas held by the then governor Rick Perry. They claim they made it rain.

          “He was mocked for it, and he went ahead and did it, and that was the beginning of the end of the drought,” [Glenn]Beck said last week while discussing Perry’s newly launched presidential campaign. “I mean, we started having rain right after that. And this state was a desert.”

          Never mind the actual facts, of course.

        4. “The difference is that dancing or praying for rain doesn’t have a placebo effect.”

          How about faith healing? Can we agree that faith healing is placebo?

          Faith healing makes people *think* they are better, without actually curing their disease. Calling out cupping practitioners is similar to calling out faith healers.

          And, again, I think we really need to be careful about using equivocal language like “real” to describe the placebo effect, whether we are talking about what faith healers do, cupping, or homeopathy.

          Faith healing is “real” in the sense their are faith healers and people think they are better, but faith healing is not real in the sense that it doesn’t actually cure the organic causes of disease. I don’t get the sense that you would argue in favor of calling faith healing “real”.

  26. True placebo effects are difficult to distinguish from various sources of bias in assessing outcomes. See:

    It is possible that athletes can sometimes perform better when they think they have done something to gain a competitive edge. That perception may enable them to be less stressed out and more focused, but it is not clear that such effects can be reliably produced. And that’s not placebo effect (the act of treating someone producing a favorable biological effect). That’s more like a coach’s inspirational pep talk which might sometimes inspire superior performance and which might also sometimes backfire.

    The promoters of cupping to athletes are deceiving them for profit. That’s health fraud:

    1. “It is possible that athletes can sometimes perform better when they think they have done something to gain a competitive edge.”

      Quite. The “mental game” is a huge factor in high level sports. At the very bleeding edge of any human endeavor our pattern matching intuition can subject to biased interpretation. Olympic level sports are just made for superstitious re-enforcement.

      Cupping demonstrably works just like N-Rays are visibly real.

  27. The placebo effect is widely misunderstood. This is a good summary I read time ago about the subject. The effect is the result of either “illusions of observation, bias, nonspecific effects, and physiological effects”.

    And for physiological effects, it’s mostly “resulting from the ritual of treatment. For example, treatment may involve relaxation or simply taking a break from your otherwise hectic daily routine. Believing one is being treated may reduce anxiety about the illness or symptoms, which in turn may reduce sympathetic activity, reduce blood pressure and strain on the heart, and reduce the levels of stress hormones. Hands-on treatments have the benefit of human contact, which improves mood and provides an overall feeling of well-being.”

    The effect is in the mind, or involves something not related to the treatment itself.

  28. And indeed, if there are effects on athletes, they probably are placebo effects. But placebo effects are real…

    I agree that this is very likely all it is. If, however, its pulling muscles ‘up,’ then I can imagine it might have some massage-like effects too. Basicalyl, just as if I was pinching your skin with my fingers, only using a tool.

    Still, even if it does have some massage-like effect, it’s a really silly and potentially harmful (not to mention, I bet more expensive) way to get a simple muscle massage.

  29. 90% of the game is half mental, as Yogi Berra said. I know stepping over the white line had no effect on my skills when I played baseball, but if the ritual calmed me and put me in a more focused state to perform, who cares? And the placebo effect may also come into play.

    The placebo effect is demonstrable, as Jerry points out, so doing something to invoke it may not be irrational. The difference between this and using homeopathy to cure cancer is that there is no pre-event course of action proven to enhance performance, whereas cancer has proven remedies. These athletes have trained to the max, have healthy diets and presumably are trying to be well rested. If they used cupping in place of all of the above, yes that would be completely absurd.

  30. Having been an elite athlete and never having done these cups I can say the effect can be real and useful, if not just psychological. People who have never been athletes have no idea that everything that is important to an athlete can all be in the mind.

  31. We absolutely should call out Olympians for using ancient nonsense.

    Olympians are highly visible, highly credible experts on health and fitness, who, one would presume, have access to the very best scientific medical treatments and advice. They are role models. Their health practices create vivid and powerful examples for others to follow. So it behooves us to point out if Olympians are using nonsense, especially if they are using nonsense that can be harmful.

    Letting alt med slide to be polite is medical accomodationism, as carpevita noted in a post above.

    This is a serious issue. Alt med is increasingly worming its way deeper into society, re-enforcing a dangerous anti-scientific mindset. It is invading prestigious university medical facilities in spite of not being backed by science. “Consumer choice” (read $$$) and other excuses are used to justify its inclusion. That is very much like the situation with Templeton trying to blur the distinctions between science and religion. We need to emphasize that science is the only tool we have for objectively separating medical treatments that seem to work from those that actually do.

    We also need to call out the placebo effect. Generally the placebo effect, in its simpler sense as a “medicine”, does not affect the organic cause of disease. People *think* they are better, but objective measurements of disease remain the same. Thinking you are better may be ok for pain, but for life threatening diseases such as atheism and cancer, placebo effect can create the dangerous illusion of improved health when, in fact, there is no real improvement.

    This article at Science Based Medicine details how asthma patients thought they could breathe better whether they were given a real inhaler, acupuncture or sham acupuncture, but actually could not. Only the inhaler made a real, measurable improvement:

    There belief that they felt better was real, but they had no real, as in actual, improvement. I think we need to be very specific about what we mean when we say the placebo effect is “real”, and make sure that our claim is based in sound science.

    I hope PCC will reconsider this issue.

    1. Doh! Autocorrect fail.

      “life threatening diseases such as atheism and cancer” should read “life threatening diseases such as asthma and cancer”

      I hope Ray Comfort doesn’t spot my Freudian Slip :-0


  32. Wait a sec. Isn’t there the possibility that cupping does work? It sure looks kooky but some of the research cited indicates there is a possibility it could have some positive effect beyond placebo.

    Carl Kruse

    1. Unlike homeopathy, cupping is bilogically plausible to have some affect on something. That something, if anything, remains unproved. What it certainly does not do is to suck out “toxins”, as it is claimed to do, nor affect non-existant magic Qi, or pretty much anything that the nonsense now called Traditional Chinese Medicine claims it does.

      “There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking.”

      — P.B. Fontanarosa, Journal of the American Medical Association (1998), via Wikipedia

  33. Credit to you for bucking the trend on this. Too many self-styled skeptics reject anything they cannot explain, which has no studies, etc. If it works it works, and the athletes (who no doubt have tried many other therapies) say it works. Also, there ARE studies:

    “This review suggests a potential positive short-term effect of cupping therapy on reducing pain intensity compared with no treatment, heat therapy, usual care, or conventional drugs.”

    Also this meta-study, which shows that cupping is effective but still recommends further study:

    Researchers correctly point out that it is very difficult to eliminate the placebo effect for therapies like this one since it’s hard to mimic the therapy without actually doing the therapy. That said, when it comes to pain, what is the difference between a “placebo” and something that works? “What works” when it comes to pain is “what gets rid of the pain”, and if cupping is getting rid of the pain for these athletes, then it is working, period.

    1. Most studies that find a positive effect using most alternative medicine treatments are poorly designed (is there a placebo control? is the trial double-blinded) and underpowered (to avoid the risk of false positives). I don’t think there’s ever been a well-designed and sufficiently powered study that’s ever found any alternative medical invention to be effective. Hence the ‘alternative’ monicker: alternative medicine that works is just medicine.

    2. “Too many self-styled skeptics reject anything they cannot explain, which has no studies, etc. If it works it works”

      Simplistic thinking like that is how bloodletting stayed with us for centuries – because practitioners all agreed it worked! Just as alt med practitioners all agree about their own current blood letting, er, alternative medicine modalities.

      The fact is bloodletting doesn’t work because Humorism is vitalistic nonsense based on trying to adjust the “balance” of non-exisitant life forces. Chinese medicine is based on the similar false, pre-scientific principles.

      Humans are highly prone to bias. Intuition can lead us to powerful, yet false beliefs. Science is the tool we use to separate what seems to work from what actually works.

      “This review suggests a potential positive short-term effect of cupping therapy on reducing pain intensity compared with no treatment, heat therapy, usual care, or conventional drugs.”

      After all the supposed thousands of years of Traditional Chinese Medicine and the best the meta study cane come up with is “suggests a potential”. That is some serious weasel-worded weak sauce, especially given that *all* of the studies were unblinded.

      1. I agree with you Scote. Just like homeopathy, alternative chinese therapy is based on a ridiculously wrong view of the human body and physiology.

        One thing to consider is that it’s often the feeling of being touched and having people talk to you that makes the pain go away. I suggest these athletes get a good lover instead.

        And homeopaths could stick with talking to their patients instead of also offering them water and sugar pills for 100 dollars each. Homeopaths are actually good at talking to patients, they have far more time than the regular doctor. That is what they should sell, not their ridiculous “remedies”.

        And maybe the cuppers could offer a long conversation and a massage to these athletes, at least that wouldn’t involve any woo. Optionally, they could open a brothel (though that would involve more risks for those involved than cupping). 😉

        1. I couldn’t agree more with your points about the benefits of massage, conversation, and prolonged attention. Most people (at least in the context of USAian culture) like to feel that they’re deserving of special attention, effort, and time, and that they should be “pampered” under certain circumstances. Some might believe that they’re entitled to such treatment. I see this with my students all the time – the more personal effort, time, and intellect I pour into a teaching method, the more it is appreciated, and likely to be perceived to “work better.” It doesn’t have to be technologically sophisticated – in fact, it’s much better if the method is more Victorian (I joke that it’s steampunk), because that necessitates more creative and manipulative effort on my part than, say, a powerpoint. If presenting such teaching approaches also required that I complete a triathlon every week, or that I dragged heavy loads up steep slopes, I’m sure they’d work even better.

          Elite athletes, such as Michael Phelps, from wealthy Western nations are among the most feted, rewarded, and pampered individuals in the world. I think one must be quite self-involved and possibly narcissistic to continue training and competing at such a level, given the number of people and the financial resources devoted to their continued success. Parents and other family, coaches, physical therapists, nutritionists, sports psychologists, massage therapists, etc. etc. Think of the carbon footprint associated with all the travel for athletes and their entourages, and with their consumption of bottled water etc. Is it any surprise that a woo technique like cupping, which requires time and effort from a specialized “therapist” and costs $$$$, has become popular with some of these athletes? They’re entitled to it, dammit!!

  34. I suppose I should state my medical opinion.

    The problematic thing about the placebo effect is that it’s not the placebo itself making people better.
    Every treatment, whether traditional or alternative, has some form of placebo effect involved. There’s been research into how to best introduce new treatments to patients, to make use of the placebo effect.
    A greater placebo effect can be achieved if the doctor is wearing a white coat, if the pill has a certain shape or colour etc.

    During my studies, one doctor told us that he sometimes makes use of placebo for particularly “difficult” patients. He knew it was unethical, but it made his life that much easier. He gave it to patients that came to him with a common cold demanding to be treated with antibiotics.
    If they couldn’t be convinced by his arguments, he gave them placebo and said it was better than antibiotics. I have sometimes wanted to do the same myself so I do understand the temptation.
    And I can understand how tempting it is for the people doing the cupping or homeopaths. They earn easy money tricking people. That doesn’t mean it’s right.

    These people aren’t being offered cupping instead of cancer treatment, which makes it less odious than many other forms of alternative medicine.
    Still, it’s contributing to the increased amount of woo we see in the media. Athletes and actors are some of the worst in the world of woo, and what they do have an effect on a large number of people. There are good chances that people starting with cupping will soon be sucked into the world of alternative chinese medicine.

    I don’t think I can overstate how much I’m starting to despise “traditional chinese medicine”. Especially all the traditional herbs with lead in them and the stupid youtube videos of supposedly non-drugged patients having acupuncture done on them while their stomach is cut open.
    I’m sick and tired of hearing people talk about how it’s been used for thousands of years, and so can’t be wrong.
    At least western homepaths can’t use the “thousand years old” argument.

    1. “Especially all the traditional herbs with lead in them”

      In addition to potential harm to patients (including failure to provide effective treatment for conditions that might be treatable with conventional medicines) there is also the very real problem that the sourcing of bears’ bile, tiger penises, rhino horn, pangolin scales, etc contributes to driving these species toward extinction (and in the case of the bears involves the use of extraordinarily inhumane treatment of captive animals).

      1. I absolutely agree. Just mentioned examples that I’ve encountered myself. Ive encountered quite a few people using chinese herbs, but none yet that use chinese medicine
        from animal parts.
        Chinese herbs are quite popular and it’s difficult to convince people that the herbs may be dangerous (many damage the liver as well) and that they have nil chance of working against their cancer.
        That’s when the “thousands of years” argument comes up and it drives me utterly insane.
        Like Scote mentioned, bloodletting stayed with us for centuries as well.

  35. The “physiological effect” search seems ethically problematical at the outset. As far as I know there is no way to get that without risking side effects in some sub-population.

    It is hard to tell from the quote, but it can be read as the trainers exposing athletes to superstition, instead of the latter asking for it. That would constitute unethical behavior, if they were doctors.

    I bet many of us have such superstitious practices.

    I assume some are asuperstitious in the same way some are atheist.

    And for much the same reasons. The rituals may make you feel good. But they don’t want to look for the man behind the curtain, to use the meme of The Wizard of Oz. Why not take a placebo pill for the same effect, and stay safe?

    Disclaimer: I am asuperstitious. I think I started outside of religion way before I became atheist specifically. So of course I am not prepared to let people chose placebo, especially “active” placebos, without knowing the risks and how the effect works.

  36. With regard to sport I’m terrible superstitious even if I know these superstitions are total nonsense. This tells me that I’ve no problem to shutdown all my rationality for a certain amount of time.

    I personally wouldn’t do cupping because it tells everyone that I’m mentally challenged or have no internet access.

    Luckily there are more discrete placebo’s.

  37. There are medical devices that involve suction to engorge parts of the anatomy with blood.

    For example, there is a device for the treatment of stings and bites from insects and other venomous animals such as snakes that is supposed to put an atmosphere of suction over the bite or sting, and is supposed to remove a fraction of the venom.

    There is a medically-approved device to treat erectile dysfunction that works in a similar way. I do not know whether or not there is a placebo effect, but it is supposed, so say the directions to keep the penis erect (when combined with an elastic ring) for up to twenty minutes. What athletic-minded person could possibly resist?

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