Constipation is a very common and heterogeneous condition characterized by unsatisfying defecation associated with infrequent stools, difficult stool passage, or both.1 In the general population, it has a prevalence of 14%, and is known to present a significant impact on the patient's quality of life,23 work productivity,4 and use of healthcare resources.456

Chronic constipation has been associated with a low level of physical activity, together with identified risk factors, including female sex, older age, poor socioeconomic status, insufficient consumption of fruits and vegetables, and psychological problems.7 Although data regarding the effectiveness of physical activity for alleviating constipation may vary,89 risk of constipation depends mostly on the level of activity, particularly in elderly individuals.10 Regular physical activity is optimal for the prevention of many chronic diseases (e.g., cardiovascular disease, diabetes, cancer, hypertension, obesity, depression, and osteoporosis) as well as premature death.11

Therefore, medical professionals have the responsibility to promote regular physical activity, both for constipated patients and patients with chronic disease. Barriers to treating lifestyle- related diseases, such as exercise, include patients' unwillingness to change their habits and their insufficient knowledge.12 YouTube is a video-sharing website that was founded on February 2005.6 The role of YouTube in medical education has long been reported. South Korea has a highly developed digital infrastructure that enable nationwide adoption of broadband Internet. There were around 45 million Internet users in South Korea by 2016.13 Increasing number of people has been obtaining and sharing a wide variety of information and knowledge from the Internet.

Previous studies have reported on the quality of information on YouTube about gallstone disease,14 Crohn's disease,15 and anal cancer.16 However, no study has assessed the quality of information on YouTube pertaining to physical activity to combat constipation. YouTube has the potential as a powerful platform for disseminating information about the use of physical activity to relieve constipation. However, its unregulated nature and the characteristics of user-generated content pose challenges for quality and accuracy control. Concerns about the indiscriminate production of unproven and inaccurate information have been constantly raised in clinical practice.

The primary aims of this study were (a) to evaluate the content quality of YouTube videos for constipated patients from the viewpoint of medical professionals and (b) to assess whether the video sources, exercise types, and popularity affected video quality.

The following keywords – in Korean – were searched on YouTube on June 10, 2017: exercise, massage, yoga, gymnastics, physical activity, and constipation. A video was excluded for the following reasons: number of views was <3,000, language of narration was not Korean, or content of the video pertained to constipation in infants and children. The approval of the institutional review board of the study institution was not required for this study.

YouTube videos were evaluated independently by eight gastroenterologists. All raters worked at tertiary hospitals and had 10 years of experience in the diagnosis and management of constipation. Seven items were evaluated: image quality, usefulness to relieve constipation, usefulness for general physical health, difficulty in following, activity intensity, fun, and overall quality. Table 1 shows each question item used to assess the quality of the selected YouTube videos. Raters were also asked open-ended questions to evaluate the strengths and weaknesses of each video.

Each upload source was categorized as commercial, media, or individual. The types of physical activity were classified as yoga, abdominal massage, and others. To assess whether popularity was related to the quality of YouTube videos, we compared the quality between the top five most-viewed videos (Nos. 6, 4, 5, 1, and 2) and the bottom five least-viewed videos (Nos. 17, 19, 15, 3, and 16).

In total, 23 YouTube videos were identified. Of these, three were excluded because they were removed from YouTube during the evaluation period; finally, 20 videos were analyzed (Table 2). The mean length of the videos was 268 seconds (range, 65–785 seconds), and each video was viewed an average of 32,694 times (range, 3,329–316,581 times). The greatest number of videos was uploaded by commercial websites (10 videos, 50%), followed by media (7, 35%) and individuals (3, 15%). The most common type of physical activity considered in the videos was yoga (n=11), followed by others (n=5) and massage (n=4). Other physical activities included stretching exercises (n=2), acupoint pressure massage (n=2), and gymnastics (n=1). None of the videos scored greater than 4 (i.e., “good to best”) with respect to “overall quality.” All videos had score a score of less than 3 (i.e., “strongly disagree to unknown”) for the quality 1 item (usefulness to relieve constipation). Only video number 2 had a “agree to strongly agree” response for the quality 2 item. Fig. 1 shows item scores based on video source, type of physical activity, and popularity.

This is the first study evaluating the content quality of YouTube videos with respect to physical activities relieving constipation by gastroenterologists. All of the videos evaluated in this study received a low score for overall quality, and none was uploaded by a medical professional. From the perspective of a gastroenterologist, regardless of the differences in the quality among video sources, types of physical activity, and popularity, many of the videos provided insufficient information to constipated patients, owing to a lack of scientific evidence. Given the high degree of agreement among the eight observers, these findings can be regarded as reliable and valid.

A systematic review concerning healthcare information on YouTube involving 18 studies indicated that YouTube was increasingly being used as a platform for disseminating health information.22 The review reported that many videos contained misleading information, were primarily anecdotal, and contradicted reference standards.22

There is little information on the effect of yoga on functional constipation.2324 One case series reported that only one of nine patients with obstructed defecation had improved clinical symptoms and normalized electromyogram pattern after yoga treatment.23 Another study found a significant change in the different domains of constipation patients' assessment of quality of life, such as reduced scores for physical discomfort (61.25%), psychological discomfort (59.21%), worries and concerns (55.92%), and satisfaction (44%) after a 1-week intervention and an integrated yoga therapy approach.

Moreover, this study also showed that none of the YouTube massage videos presented an accurate description of the massage type, adverse events, and contraindications. A systematic review that included only four controlled clinical trials indicated that abdominal massage was a promising approach for treating chronic constipation.25 The type of massage used in the studies included in the systematic review was heterogeneous. Abdominal massage therapy is not totally devoid of risk. A case series reported several adverse events, such as ruptured uterus, displacement of ureteral stent, hepatic hematoma, colon rupture, and cranial hemorrhage of fetus.26 Although the method, efficacy, and safety profile of abdominal massage for the relief of constipation remains unclear, the general lack of this information is of particular concern because constipated patients can develop complications. Contraindications for abdominal massage include a known or suspected abdominal obstruction, abdominal mass, recent history of radiotherapy to the abdomen, <6 weeks post-abdominal surgery, strangulated hernia, and not wanted by the patient.27 In addition, many massage videos had misleading information. For example, “self-massage to Cannon's point is helpful for a bowel movement because this point is the starting point of colon peristalsis”. However, Cannon's point, encountered during a barium enema, is a transient segment that narrows at a discrete point in the transverse colon.28 It is thought to be the junction of the innervation between the mid-gut and hind-gut. There is no clinical significance to the Cannon's point and no proven effect from massaging this area.

Complementary and alternative medicine (CAM) is widely used in South Korea.29 It is not surprising to see videos of acupoint pressure massage on YouTube, despite the lack of scientific evidence regarding the effectiveness of this approach. In fact, both yoga and massage are part of CAM. The reasons for the increased use of CAM include increased availability of information on the Internet, the perception that CAM is easier to understand, safer, and less expensive than conventional medications, and distrust and frustration with the healthcare system.30 One European survey reported that about 30% of constipated patients are dissatisfied with their treatment, and such dissatisfied patients were more likely to be interested in other treatments.31

In one study that investigated the relationship between Korean consumer characteristics and utilization of health information on the Internet, the utilization rates were higher for consumers who were young, educated, working in an office setting, had a higher income, wanted health information, and were able to use the Internet.32 A better understanding of the characteristics of Internet utilization by Korean consumers for health information will help to develop YouTube contents that are effective regarding the use of exercise to relieve constipation.

We were unable to search for any videos pertaining to aerobic exercise. The effect of aerobic exercise on healthy subjects or trained athletes has been questioned based on the mouth-to-cecum transit time.3334 In contrast, a few studies involving healthy subjects have shown that colonic transit time decreases with physical activity.3536373839 Physical exercise in untrained subjects increases colonic propagating activity, which may enhance colonic propulsion.40 There is increasing evidence suggesting that exercise may alter the gut microbiome in animal models.41424344 In a human study, exercise was related to gut microbial diversity.45 In a study involving middle-aged inactive patients with constipation, stool consistency, other constipation symptoms, and colon transit time improved in response to moderate physical activity of 30–60 min/day (e.g., brisk walking).9 Furthermore, YouTube videos regarding the effects of aerobic exercise on constipation should be uploaded and/or monitored by medical professionals.

Pelvic floor physiotherapy has been utilized extensively over the past decades for the treatment of pelvic floor dysfunctions.46 There is accumulating evidence that a combination of pelvic physiotherapy and laxatives are more effective in relieving constipation.4748 The core of this therapy is diaphragmatic breathing, which strengthens the abdominal muscle contraction, improves coordination between abdominal muscle and pelvic floor muscle, and enhances the colonic propulsion. Further evidence-based YouTube videos should be introduced for constipated patients, in which the physiology of abdominal breathing applied and its correct technique would be comprehensively explained.

A few limitations are inherent in our study. There is no robust evidence regarding the effect of exercise on constipation symptoms. It remains unclear what kinds of exercise are effective for improving constipation symptoms. Gastroenterologists participating in this study were unable to suggest any exercise that would be helpful for bowel motility. However, we were able to identify the videos for relieving constipation that had no exercise effect at all or non-scientific contents. Second, no validated, objective tools exist to evaluate the quality of YouTube videos. As such, the assessment was subjective. However, the quality evaluation is unlikely to have been flawed given the high level of expertise and high interobserver agreement. Third, our study design focused on Korean YouTube videos; hence, our results may not be broadly generalizable to other countries. Given the limitations and poor quality of YouTube videos reported in other studies,22 the results of video studies in other languages are unlikely to differ much from our results. Finally, our study design was cross-sectional and was able to capture only a single snapshot of the information available on YouTube. The information available on the website changes with time.

In conclusion, Koreans searching YouTube videos pertaining to useful exercises for constipation relief are presented with low quality content. Although the content quality differed statistically among video sources, the type of physical activity, and popularity, none of the videos was appropriate for constipated patients. Constipated patients, in particular, rely increasingly on internet-based resources, such as YouTube videos, to manage their condition. As such, physicians need to recognize the potential influence of YouTube videos on patients' perceptions of their condition and the effect on the physician-patient dialogue. This study highlights the need for both evidence-based comprehensive educational videos addressing exercises for coping with constipation and well-designed research to evaluate various types of exercise (including CAM) to relieve constipation.