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Neurology Today:
doi: 10.1097/01.NT.0000420992.32872.b0
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Would You Prescribe YouTube for Vertigo? A New Study Has Something to Say About That

Rukovets, Olga

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ARTICLE IN BRIEF

In a YouTube search last August, Kevin Kerber, MD, and colleagues analyzed for accuracy 33 videos, which demonstrated the entire Epley maneuver for treating benign paroxysmal positional vertigo.

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Increasingly, video instructions for the Epley maneuver (EM) — an effective repositioning technique for treating one of the causes of dizziness, benign paroxysmal positional vertigo (BPPV) — are being uploaded to YouTube, and both patients and medical professionals are using the videos for treatment and/or education, according to an analysis of video views reported in the July 24 online edition of Neurology. But whether that is a helpful development or not is yet to be determined.

The EM involves sequential movement of the head into four positions, staying in each position for roughly 30 seconds. [See illustration.]

Lead study author Kevin Kerber, MD, assistant professor of neurology and director of the Dizziness Clinic at the University of Michigan Health System, and colleagues, wanted to determine if the YouTube demonstrations were accurate and to assess the comments by viewers.

In a YouTube search last August, Dr. Kerber and colleagues identified 33 videos which demonstrated the entire EM, with more than 2.7 million views. The most popular video (802,471 views) was produced by the AAN (visit: http://bit.ly/TCIeyF). Five of the videos accounted for 85 percent of all the views, and 64 percent (21 videos) were rated accurate.

DR. TIMOTHY HAIN: Di...
DR. TIMOTHY HAIN: Di...
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The 424 posted comments indicated that some patients were actually self-treating with the maneuver after reviewing the videos, and that some providers were using the videos as a prescribed treatment or for educational purposes.

Many of the videos were demonstrating the maneuver correctly which was encouraging, Dr. Kerber said, and the comments also suggested that some people were using the videos to both self-diagnose and self-treat their symptoms — a finding that was enticing from a health care efficiency standpoint. However, the comments also showed that patients might be having some trouble deciding whether or not they have BPPV, he said.

Dr. Kerber said the researchers are working to develop a research trial to look at whether certain video interventions are more likely to be effective than others and to compare video interventions with routine care.

For any effective intervention, he said, the way information is disseminated to both physicians and patients is a critical part of the process — “and the Internet seems to offer vast possibilities in that regard.”

The problem with the Internet, though, Dr. Kerber said, is in testing such interventions — “recruiting the appropriate patients, defining outcomes, and collecting outcomes of patients who are subjected to interventions like this. So there are some significant challenges to doing that kind of work, but I think it has important potential.”

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EXPERTS COMMENT

Another aspect to address in a future study, said Mark Walker, MD, associate professor of neurology at Case Western Reserve University School of Medicine, would be the impact of such interventions on reducing health care costs — though, again, these outcomes would be difficult to measure.

“There are other treatments for BPPV and maneuvers that have the same effect — the uniqueness of BPPV treatment is that it can be carried out by the patient and it can be visually demonstrated,” said Dr. Walker, who was not involved with the analysis.

That is what makes it most suited for YouTube, Dr. Walker said. There is a definite value to having this type of information available on the Internet, where it can be used by both physicians and patients, he said.

“A lot of times when we see these patients we have to send them home to do post-treatments because a single office treatment isn't effective in eliminating the problem. This is a way for them to have a resource to consult,” he said.

Timothy Hain, MD, professor of neurology, otolaryngology, and physical therapy/human movement science at Northwestern University Medical School in Chicago, IL, said that it is not surprising that these videos would be helpful to patients. “BPPV is a condition where people are often quite good at self-diagnosing. When people come into my office, and tell me that they have BPPV — I think that roughly 95 percent of the time they hit it on the head.” Dr. Hain was one of the authors of the AAN's 2008 practice parameter on BPPV (neurology.org/content/70/22/2067).

Because BPPV is a condition that you can “fix in a hurry,” it doesn't fit in with our traditional model of subspecialty care “where you get sick and then you try to get a doctor's appointment and have to wait,” Dr. Hain said. In other words: YouTube is more readily available than physicians are, Dr. Kerber added.

However, with this convenience come some potential dangers — especially when the videos become a primary patient resource. For example, Dr. Hain said, a patient may misdiagnose BPPV when he or she really has a more serious condition. “It's extremely rare, but someone who thinks they have BPPV may really have a brain tumor, and I've been doing this so long that I've seen this happen a number of times.”

Dr. Kerber recommends caution for both patients and physicians in using these videos for medical reasons. Some dizziness patients actually have dangerous causes, like stroke, which they may misinterpret as BPPV. In this case, the delay of care could be potentially life-threatening. Many patients may not be able to decipher accurate from inaccurate information or even be able to perform the maneuver on their own, Dr. Kerber added.

Another more real danger, Dr. Hain said, is that when people self-treat, they may get into trouble. “When we treat people in the clinic, maybe 5 percent of the time they have a canal conversion, where they convert posterior canal BPPV, a rather benign condition, into lateral canal BPPV, which is more disabling.” If it happens in the clinic, he said, as evidenced by a change in the direction of the nystagmus, we can treat it right away — “by changing from a maneuver used for posterior canal treatment (e.g. Epley maneuver) to a maneuver used for lateral canal treatment (for example, the Gufoni or the Logroll).” But at home, patients won't know what has occurred and how to fix it.

Most of the videos, Dr. Walker pointed out, do not stress the significance of which ear the procedure should be performed on — and this is necessary for proper treatment. “If the video does not demonstrate the procedure correctly — and some don't, or if the patient thinks they have BPPV but really don't, they are treating the wrong problem.

“I think it's an interesting study, but a lot more information would be needed to see how effective these videos are … which is almost impossible to do,” he said.

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CAN YOUTUBE REPLACE THE DOCTOR?

The experts disagreed on the ideal use of these videos — whether they could serve as primary or secondary sources for treatment. Dr. Hain said that patients should at least see someone competent in diagnosing BPPV (not necessarily a neurologist) before self-diagnosing — usually a vestibular physical therapist is most accessible — and self-treating.

“It's fine to look for and access information but bring that information to the doctor and discuss it with him or her. And use that as a supplementary resource rather than as a primary source of information. It won't replace the doctor,” Dr. Walker said.

However, Dr. Kerber said, ideally, “there is probably a segment of the population that could diagnose and self-treat BPPV even without seeking a professional opinion first. I think there is a potential role for that.”

It would be best to have at least some official and trustworthy link associated with the videos and some method of finding out online what could go wrong, the commentators agreed. Dr. Hain said, “I'm not so fond of YouTube, but I do think that a legitimized video network to help patients identify their problem would be immensely helpful.

“Dizziness is a very rough problem for patients because it can be due to their ears or it can be due to migraines or their low blood pressure or due to medication interaction. If a patient is dizzy and doesn't really know which doctor they should go to see, they can end up wasting a huge amount of time and resources just going from one to the other and being referred to different clinics. If people could safely educate themselves online, it would make our system much more efficient,” said Dr. Hain.

Dr. Timothy Hain, of Northwestern University Medical School, discusses the potential risks and benefits associated with using YouTube and other Web sites for the treatment of vertigo: http://bit.ly/MXBT0t.

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For the video demonstration of the Epley maneuver from the American Academy of Neurology, visit http://bit.ly/TCIeyF.

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REFERENCES:

• Kerber KA, Burke JF, Fendrick AM, et al. A prescription for the Epley maneuver: www.youtube.com? Neurology 2012; 79(4):376–380.

• Fitzgerald S. A positioning maneuver or head shaking can relieve symptoms of vertigo. Neurology Today: http://bit.ly/Ofxncq.

• Fife TD, Iverson DJ, Gronseth GS, et al. Practice parameter: Therapies for benign paroxysmal positional vertigo (and evidence-based review) - Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:2067–2074.

• Samson K. New AAN guideline on vertigo. Neurology Today: http://bit.ly/NBzO6m.

©2012 American Academy of Neurology

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