Video demonstrations of a common maneuver for managing benign paroxysmal positional vertigo (BPPV) are readily available on YouTube, and most are accurate depictions of the treatment, according to a new study.
The study, published in the July 24 issue of Neurology, shows that 64% of 33 videos had correct information on how to perform the Epley maneuver, with most of the other videos having only minor deviations from the accepted approach, said lead author Kevin A. Kerber, MD, assistant professor of neurology at the University of Michigan Health System in Ann Arbor.
A relatively common condition, BPPV is caused by freely moving particles called canaliths that are trapped in the semicircular canal of the inner ear. A main symptom of BPPV is transient, positionally triggered dizziness.
The Epley maneuver involves a series of easy steps designed to move particles from the canal, including the following:
- turning the head 45 degrees toward the affected ear while in an upright position
- lying back quickly with the head extended below the shoulders
- moving the head 90 degrees toward the unaffected side
- turning the head another 90 degrees so the patient is nearly in the face-down position (usually requires rolling over on the side), and
- getting back up to a sitting position.
The maneuver has been proven effective in rigorous randomized trials and is included in guidelines on treating BPPV, said Dr. Kerber. “If you want to treat someone effectively, this is it.”
According to Dr. Kerber, however, this treatment is not widely used. “There haven’t been that many studies looking at this, but every one of them suggests that this maneuver is underutilized.” It is possible that physicians recommend the maneuver but just do not record it, he said.
After performing a systematic search and selecting videos that demonstrated the entire Epley maneuver and that were available on YouTube up to August 30, 2011, researchers abstracted information from each video, including its duration, posting date, and number of views, and related comments from viewers. They categorized the videos as demonstrating guided treatment or self-treatment, and as showing the maneuver for right-sided BPPV, left-sided BPPV, or both.
Researchers also determined whether the videos included diagnostic information and were accurate in the time spent on each position of the maneuver (most should last at least 20 seconds).
The videos appeared to come from a number of different sources, said Dr. Kerber. Most seemed to have been made by healthcare providers, including physicians and physical therapists, but some were likely made by patients in their home.
The total number of hits for all videos was 2,755,607. The most widely viewed video (with 802,471 hits) was produced in 2008 by the Practice Parameter on BPPV of the American Academy of Neurology (AAN). That video, along with 4 others, accounted for 85% of hits for all videos.
The researchers rated almost two thirds of the videos (64%) as accurate demonstrations of the maneuver. Most videos (82%) provided accurate time spent on each position. However, none of the videos included complete diagnostic information about BPPV.
Reasons for inaccuracies included things such as patients turning their head more than 45 degrees, or the head not being extended back far enough. “One of the key things about the maneuver is lying all the way back with the head way back, kind of on the end of a table,” said Dr. Kerber. “Some of the videos just had the person lay back flat, which we don’t think would get the particles to move enough to be effective.”
In some videos, the movements were too slow, or the head was lifted during the rollover step. “If you do that, the particles can fall in the opposite direction to where you want them to go,” he said.
Although inaccurate movements could fail to remove particles from the canal, the maneuver is, for the most part, very safe in that it involves no more than lying down and rolling over. What could potentially be dangerous, however, is if a patient has a stroke, looks the symptoms up on YouTube, comes across one of these videos, and mistakes the symptoms for BPPV. “In that case, they waste time rolling themselves around and delaying potential treatment,” said Dr. Kerber.
Accuracy but Not Outcome
The authors rated the videos only on their accuracy and did not rank their quality in terms of outcome. That, said Dr. Kerber, can be done only through a randomized controlled trial.
Physicians do not appear to be recommending this treatment, or even learning about it. “When I talk to medical students, they may have heard of it, but they don’t know how to do it,” said Dr. Kerber.
Because dizziness bridges several specialties, including general medicine, otolaryngology, and neurology, information on the Epley maneuver may “fall through cracks,” he said.
Many physicians prescribe medicines for patients with BPPV, which can be a problem because many of these drugs are sedating, said Dr. Kerber. “Then you have someone walking around who is not only dizzy, but also sedated.”
Some patients are told just to wait it out, and that the vertigo will resolve in 6 to 8 weeks. “The condition is called benign because you’re not going to die from it, but it’s not benign in terms of symptoms,” said Dr. Kerber. “People who have it report missing work, having to stop driving and their normal routine of activities, and sometimes having to go to the emergency department.”
More than one third (39%) of the videos had at least 1 accompanying comment. Judging from the reviews, patients use the videos to self-treat. Many said that the videos were beneficial, even describing the maneuver as a “miracle,” but others said that they tried the maneuver and it did not work, which, said Dr. Kerber, suggests that they do not have BPPV.
Another theme that emerged from the comments was that healthcare providers use the videos as a prescription for patients or for educational purposes.
When approached for a comment, Timothy Hain, MD, professor of neurology, otolaryngology, and physical therapy/human movement science at the Northwestern University Feinberg School of Medicine, Chicago, Illinois, raised the issue of plagiarism. He said that sharing of educational health videos on social media is a major problem. “I have noticed at least 5 of my own videos pirated on YouTube,” Dr. Hain told Medscape Medical News.
Many of his BPPV treatment protocols from copyrighted material have been uploaded illegally, and without giving proper credit, he said. This, he added, is “immensely discouraging” to content providers, who do not get paid for their very expensive content creation.
Dr. Hain also finds the quality of the videos generally rather poor, in part because of time limitations. “It’s impossible to substitute a 1-minute video for a 30-minute healthcare provider encounter,” he said.
In addition, there are the problems inherent in any “self-treatment” approach, for example, patients may not be able to determine the correct side, or they mistake a more sinister type of dizziness such as a brain tumor for BPPV, and waste time with home treatments, he said.
However, said Dr. Hain, the videos do lower healthcare costs, and the treatment they depict is “pretty benign.”
Ronald Tusa, MD, PhD, from the Departments of Neurology, Otolaryngology, Ophthalmology, and Rehabilitation Medicine at Emory University, in Atlanta, Georgia, whose research interests include causes of disequilibrium, found the study useful. He already teaches patients the Epley maneuver and includes a description of it in handouts.
“Based on this study, on the sheet I give to patients, I will probably include the YouTube site,” where they can find the correct demonstration of the maneuver, he said.
But patients tend to lose the sheet, he noted, and because it may be difficult to find an accurate video just by searching YouTube, Dr. Tusa said it would be a “great idea” if the AAN included its video on its Web site, so patients can easily access it. (By Pauline Anderson)
Dr. Kerber is funded by the National Institutes of Health/National Center for Research Resources and the Agency for Healthcare Research and Quality; has received speaker honoraria from the American Academy of Neurology, Munson Medical Center, and the University of Utah; has served as a consultant for the American Academy of Neurology; has served as a one-time consultant for Pierre Fabre and as an expert witness for Estes, Ingram, Foels & Gibbs, P.A.; and receives publishing royalties (anticipated) for Clinical Neurophysiology of the Vestibular System , 4th edition. Full disclosures are available on the journal’s Web site.