Candidates belonging to the FMF were classified based on the AAO-HNS criteria for Ménière’s disease. The criteria show either definite or probable Ménière’s disease (Table 1). Thus, if the criteria were probable of Ménière’s disease, 35 people with possible Ménière’s disease would be excluded.

The algorithm of the inference engine compares the diagnostic criteria and symptoms between 14 different conditions and provides fitness scores for each condition. The program suggests the condition with the highest score as the principal diagnosis and provides as diagnostic alternatives the second and third possibilities if their scores exceed a probability of 0.5. Out of the 740 cases, the program accepted 706 as Ménière’s disease and 19 cases were rejected. In all cases, however, Ménière’s disease was the most likely diagnosis. The rejection was done on the basis of the score S(d) mentioned above. If the score S(d) was more than 0.43, the person was allowed to attend the program. In Table 2, variables are presented where the differences in mean values were statistically significant in variance analysis at a risk level of P<.001 between the groups, where S(d) was either less than or over 0.43. A histogram of S(d) scores is presented in Figure 3.

In order to enter the peer-support program, the condition should have an impact on the person. In the quality of life measurement, if the visual analogue scale (VAS) score is 95% or less, the person can access the peer-support program. With VAS scores greater than 95%, the person would not benefit from the intervention but will still be able to access the information package. With the data from the pilot group, all candidates had Ménière’s disease but their S(d) scores varied between 0.15 and 0.92 while the maximum value was 1. The higher the score, the better the match to Ménière’s disease. However, low S(d) values might indicate that the person can benefit more from another form of rehabilitation. For instance, a personally tailored and conducted physical training regime could be an appropriate choice. Candidates with an S(d) value that’s less than 0.43 are older and their vertigo characteristics are less severe than those with an S(d) that’s more than 0.43. The reasoning for a certain threshold is difficult, but in this work we determined the threshold value statistically. By using two standard deviations we cut the left “tail” of the low-end distribution (Figure 3). This excludes 2.6% of candidates from the peer-support program. On the basis of Table 2, these candidates are also seen to have less severe symptoms than the others.

Several investigations have evaluated the psychological aspects of Ménière’s disease [40,45-48]. In general, the authors have focused on mood, anxiety, and personality traits. Söderman et al have indicated that personality traits measured with sense of coherence scale correlated with disability in Ménière’s disease [45]. Hägnebo et al evaluated the psychological correlates of vertigo attacks and studied 514 subjects diagnosed with the condition [47]. Principal component analyses showed that the somatic sensation scale could be divided into 2 subscales: (1) dizziness, vertigo, and anxiety, and (2) sensations in the ear. The psychological state scale showed an energy/awareness factor and a negative emotional state factor. The situation characteristics scale showed 2 factors: (1) environmental disturbances and (2) stressful conditions. Thus they considered fatigue as a psychological component of the disability, whereas anxiety was seen as a somatic component. Vitality is a key component in several indices measuring quality of life (eg, 15D, SF-36), as well as in the perception of “wellness” [49].

Levo et al reported that among subjects with Meniere’s disease, about 70% of the subjects felt fatigued and in 30% this fatigue was moderate to strong [50]. Fatigue was associated with a reduction in general health-related quality of life and also associated with vertigo attacks, balance problems, and hearing loss. The authors concluded that among consequential factors, mobility and anxiety were the strongest consequences of reduced vitality. Among predisposing factors, a sense of coherence and attitude were significant predictors. Further analysis based on participation restrictions indicated that isolation is a severe consequence of a reduction of vitality. Based on the observations of Levo et al, we made an effort in this peer-support program to bring both fatigue and anxiety into the participants’ awareness and by working with the computer program to interactively guide participants to more positively change their attitude to regain social activity [50]. In chronic persistent diseases such as Ménière’s disease, it has been suggested that the evaluation and appraisal of stressors and their subsequent management will improve coping with the disease [51]. In chronic Ménière’s disease, reduced vitality is a common complaint and, especially in its severe form, it should be recognized and included in any therapeutic procedures that are undertaken.

Ménière’s disease is a chronic, progressive disorder that is defined and diagnosed based on the patient’s clinical symptoms. However, previous studies have shown no consistent temporal pattern between the perceived levels of stress and any of the core symptoms of the disease [52]. In Ménière’s disease, patients without significant vertigo spells or incidents of psychological signs such as depression and anxiety associated with the dizziness handicap are comparable to that of a control group. In addition, individual differences emerge and the time resolution for analyzing the association of stress and the psychological aspects associated with the Ménière’s disease may require relatively long-term observation. However, the reciprocal connection between psychological factors and complaint behavior in Ménière’s disease is difficult to resolve [46,53], as among people with Ménière’s disease, personality trait and anxiety were interrelated [50]. Van Cruissen et al indicated that the psychological profile of Ménière’s disease patients seems comparable to patients with other chronic conditions [53]. In their study, Kirby and Yardley indicated that their Ménière’s disease group reported more depression and “health anxiety” than the healthy control group, and that “health anxiety” was associated with anxiety and depression [46]. After controlling for the severity of the symptoms, anxiety was associated with several illness perception subscales, including emotional representations, consequences, psychological causes, and the tolerance of uncertainty. Contrary to this, however, Brantberg and Baloh considered fatigue to be a trigger for Ménière’s disease [54]. In line with Kirby and Yardley [46] and Levo et al [50], in the computerized peer-support program we consider that the reduction in vitality is a consequence of the condition (in this case vestibular dysfunction) rather than a causative factor. Personality trait has been also been regarded as a modifying factor for the condition [50]. Moreover, the relatively minor role of personality trait in quality of life and disease-specific impact has been previously documented [40,45,46].

An optimistic view of the future results in better adjustment outcomes, since optimists tend to continue with their adaptive coping efforts when confronted by adversity [55]. In Ménière’s disease, we observed that a positive attitude improves coping with the condition and improves quality of life [17,19]. It is of note that the subjects did not identify any wishful thinking (ie, a miracle improvement) or escape-avoidance coping (ie, trying to forget the disease) that have been otherwise regarded as strong predictors for mal-adjustments in neurological disease [51]. A positive attitude has been associated with lower depression, less anxiety [56], and better physical and social adjustment [57,58]. By bringing up positive aspects in the peer-support program, we aim to improve coping. However, before launching the program to a wider market, the validity and user satisfaction of the program must be certified. For validation we are using changes in the quality of life instrument [21] and in the post-traumatic growth inventory [24].

Several computerized peer-support programs have been recently launched on the Internet. For instance, programs on diabetes care [59], coping with bulimia [60], bipolar mood disorders, anxiety (eg, Beat the Blues, Cope) [61], phobias and panic (eg, FearFighter) [62], obsessive-compulsive disorder (eg, BT Steps) [61], and tinnitus [15] are now present. 

All of these programs use questionnaires and provide instructions to stimulate behavioral changes in order to cope better with the featured condition. The effectiveness of Beat the Blues, Cope, FearFighter, and BT Steps have been considered from a cost/benefit point of view [61]. Computerized treatment can yield savings and provide benefits for patients that are comparable to the therapy provided by physicians [15,61]. The effect of the tinnitus peer-support program for the person was found to be as effective as that of a personal support program [62].

By definition, the expert system is a set of programs that manipulates encoded best knowledge to solve a problem in a specialized domain that normally requires human expertise [35,63]. The program is adaptive and learns during use (ie, a new person’s data updates the database). The solutions to problems will converge to the best possible solutions available during the course of the program. If information is not appropriate for the condition, it will not be included in the alternative diagnostic choice.

A symptom-based classification method is recommended by AAO-HNS [64] to make the diagnosis, and this has been used in the present study. Indeed, in a taxonomic investigation of patients with vertigo, after the exclusion of neurological and middle-ear conditions, head trauma, and ototoxicity, Hinchcliffe has found that those with “classical” Ménière’s disease (ie, those meeting the “probable” definition based on the AAO-HNS definition) fell into a single nosological entity with all other cases of vertigo [65]. He later argued that Ménière’s disease included “formes frustes,” where the triad of symptoms is not complete [65]. The AAO-HNS has proposed the currently used classification. It defines “possible Ménière’s disease,” “probable Ménière’s disease,” and “definite Ménière’s disease.” “Certain Ménière’s disease” is diagnosed by the symptom entity and histological verification of endolymphatic hydrops in the inner ear. To define the condition clinically, however, the existing AAO-HNS classification is unhelpful [65]. In a recent study, Pyykkö et al used MRI to diagnose endolymphatic hydrops and found that all patients with definite Ménière’s disease had endolymphatic hydrops [66]. Patients with probable Ménière’s disease had endolymphatic hydrops in 95% of cases. Thus, the current criteria for inclusion of people with definite and probable Ménière’s disease into the program seems to be quite accurate, although some cases may be erroneously classified. In a previous study we compared the accuracy of the inference engine and different vertiginous disease diagnoses made by human experts [67]. With the same set of data, the current inference engine correctly diagnosed 65% of the cases, while younger physicians succeeded in 54% and the experienced physician in 65% of the cases [67].

The selected user interface solutions follow the ideas presented in the work of Hawthorn [68]. Hawthorn stated that most difficulties in the use of a computer originate from a degradation of vision, cognitive ability, and motor control. In our program, the automatic data saving removes the burden from short-term memory, and stationary screens are easy to follow and minimize the need for scrolling, which helps users who may have problems with their motor control.

One major problem is how to construct simple and clear sentences for the questions. In addition, a certain amount of guidance is needed in problematic situations. The program contains help topics and best practices drawn from other participants. If a mouse remains stationary on the questionnaires, a short tooltip shows additional help. This help is available either as a short text or as an example form that shows what the user should do next. The help information docks on the particular page and does not branch the program flow. This prevents the user getting lost in the program. The task in question is always visible on the screen.

The questionnaires in the program also contain open-ended questions and fields for the person’s replies. These replies are stored in the database. The open-ended questions are ultimately used in providing useful self-help items and coping strategies [39,42]. After completing each questionnaire, the person is informed how he/she compares with other persons. The purpose of feedback is 3-fold: (1) it tells the user where he/she stands with their problems when compared to other participants [18]; (2) it enables the progress of the program [35]; and (3) it reinforces learning and motivation [69]. In some self-help programs [15,62], the commitment of users appears to present a problem.

A usual method to reinforce learning is to use forced-choice tasks. By focusing on 3 major problems and ranking them, the program helps the person to focus and identify the major impacts of the disease on his/her life [41,44]. In this decision-making process, the person ranks the impacts and tries to maximize the beneficial outcomes. In the program, these actions are continuously revised by the application of strategies leading to improvement [70]. This type of reinforcement learning leads parsimoniously to improvement as indicated by behavioral and neurophysiological studies in humans [69]. In addition to problems classified based on ICF, the program also uses positive experiences to reinforce attitude and personal trait [17,71]. Neurophysiological theories indicate that by reinforcing positive experiences, new synapses are established and the synaptic efficacy is improved. This has a stabilizing effect on the organism, either via improved neural transmission or via targeted synaptic triads [72]. Thus, the use of positive aspects will break down negative reinforcement and allow the nervous system to recover and learn new rules. In this manner, positive aspects work as rewards and allow internal evaluations of covert motor actions without defining them as behaviors [73].

Most often, expert teams build these programs without establishing any solid data collection from individuals. Our computerized peer-support program for Ménière’s disease offers a difference, in that it uses an inference engine based on pattern recognition to reveal the accuracy of the diagnosis. It also profiles individual cases with a nearest neighbor classification algorithm and provides peer-support based on real-person oriented data.