QUALITY

OF LIFE

IN VERTIGO

PATIENTS:

A DOUBLE-BLIND

COMPARATIVE

STUDY

OF A HOMEOPATHIC

MEDICATION

Wolfgang Strasser, Michael Weiser

Quality of Life in Vertigo Patients: A Double-Blind Comparative Study of a Homeopathic Medication

Introduction Abstract Nearly 10% of all patients seen by physias

suffering nificantly patient's only patient's severity quality reopened

that the basic ailment vertigo patients (3). Therefore, total situation

imposes varies sigof a not and the the has of not of

on individual

Quality-of-life issues and accurate observation of symptomscan be essentialin selecting.individually appropriate pharmaceuticaltherapy for vertigo. .Forthis reason,the present study comparesthe effects of Vertigo heeland betahistine .not only with regard to the frequency,duration, and intensity of vertigo attacks but also with regard to quality of life .in patients with vertigos of varying etiology. The double-blind study incliJdeda total of II 9 patients from IS practices.Treatment was administeredthree times daily for six weeks and consistedof either IS drops of Vertigoheelor 6 mg of betahistine. Quality of life was assessed by meansof two psychometrictests, the SF-36Health Surveyand a vertigo-specific questionnaire.Quality of life (measured in terms of both physical and psychologicalwell-being) improved significantly during therapy with Vertigoheel,which proved to be equivalent to betahistine therapy. Keywords: Vertigo heel, betahistine,vertigo, clinical study, quality of life

cians in family practice name dizziness one of the symptoms lem (1). Primary-care whether wonder physicians

assessment must include measurable but also

of their health proboften tests of the the

technologically symptoms subjective of life.

an initial physical exami-

quantifiable

nation and a few simple, common

perception perspective

coordination can adequately pinpoint cause of this condition or whether patient will have to be referred cialist for further examination. cases, targeted indeed severity extensive tagmus determine

of his or her illness as it impacts This the discussion therapies, drugs on a number including

to a speIn most can and more nys-

pharmacological only antivertigo mines increasingly,

tests of coordination the exact etiology If needed, may include

but also antihistamedications; value is perspec-

and hemorheological their

of the vertigo. examination analysis, (2).

therapeutic

being considered

from additional

electronystagmography,

or posturography

tives. This basic approach was given special consideration in the current clinical trial of Vertigo heel (drops) versus betahis-

A patient who fears sudden

attacks of ver-

tine in patients etiology.

with vertigos

of varying

tigo may avoid physical exertion and psychological stress and withdraw from social activities. Because such avoidance is

...................................................................................

often

associated

with depressive therapeutic

loss of subsetar-

COMMENTARY

self-esteem

that affects the patient's

quent behavior,

measures

get both the frequency and the severity of the attacks in order to improve the patient's quality of life and thus his or her state of health. research groups, subjectively The findings however, objectively ical pictures perceived

' .

A randomized double-blind study by Weiser et al. comparing the efficacy of Vertigoheel and betahistine was published in Arch Oto-

laryngol Head Neck 1998. While that first paper focussed on efficacy and tolerance of the two medications, this second article adds the parameter of quality of life and is therefore

of various involve determined

reveal that patients' more

overall clinthan just the

more than just an afterthought

to the first.

Taken together, these two papers provide an example of evidence-based medicine. This procedure should become the accepted standard because it demonstrates how quality control can be implemented in biological medicine. The results of this study, by confirming the equivalence of the antihomotoxic medication and the allopathic drug in improving quality of life, also document the cost effectiveness and lack of adverse effects of antihomotoxic therapy for mild forms of vertigo. Hartmut Heine, Ph.D. .

degree of severity

of their vertigo. In the process of subjective evaluation and care of individual vertigo patients, physicians repeatedly find

that even when they observe and document similar clinical conditions and functional limitations and in patients, subjective substantial of of

differences behavior

are evident

in these patients' perceptions life situ-

health Depending

on personality,

ation, and individual

values the burden

......................................................................

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QUALITY

OF LIFE

IN VERTIGO

PATIENTS:

A DOUBLE.BLlND

COMPARATIVE

STUDY

OF A HOMEOPATHIC

MEDICATION

Question I : In general, wouldyou sayyour healthis: Scale: excellent; very good;good;fair; poor
Question 2:

a. Cut down on the amount of time. you spent on work or other activities b. Accomplishedless than you would like c. Were limited in the kind of work or other activities d. Had difficulty performing the work or other activities (for example,it took extra effort) Scale: yes, no Question 5:

Scale:
not at all; a little bit; moderately;quite a bit; extremely Question 9:

Comparedto one year ago, how would you rate you[ health in general now? Scale: much better now than one year ago; somewhat better now than one year ago; about the same as one year ago; somewhat worse than one year ago; much worse than one year ago. Question 3:

These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weekL a. Did you Jeel foil of life? b. Have yoU been very nervous? c. Have you felt so down in the dumps that nothing could cheer you up? d. Have you felt calm and peaceful? e. Did you have a lot of energy? f. Have you felt downhearted and depressed? g. Did you feel worn out: h. Have you been happy? I. Did you feel tired? Scale: all of the time; most of the time; some of the time; a little of the time; none of the time

The following questions are about activities you might do during a typical day. Doesyour health now limit you in these activities? If so, how much? a, Vigorousactivities such as running,lifting heavy objects, participating in strenuous sports b. Moderateactivities, such as moving a table, pushing a vacuum cleaner,bowling, or playing golf c. Lifting or carrying groceries d. Climbing several flights of stairs e. Climbing one flight of stairs f. Bending,kneeling, or stooping g. Walking more than a mile h. Walking several hundred yards i. Walking one hundred yards

During the past 4 weeks,have you had any of the following problems with your work or other regular daily activities as a result of any emotionalproblems (such as feeling depressedor anxious)? a. Cut down on the amount of time you spent on work. or other activities b. Accomplishedless than yoo would like c. Did work or activities less carefully than usual Scale: yes, no Question 6:

Question

10:

During the past 4 weeks,to what extent has your physical health or emotional problems interfered with your normal social activities with. family, friends, neighbors,or circle of acquaintances? Scale: Not at all; slightly; moderately; quite a bit; extremely

During the past 4 weeks,how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)? Scale: all of the time; most of the time; some of the time; a little of the time; none of the time Question II: How TRUEor FALSE is each of the following statements for you?

Questfon 7:
How much bodily pain have you had during the past 4 weeks? Scale: none; very mild; mild; moderate;severe;very severe

j. Bathing or dressing yourself Scale:

yes,limited a lot; yes,.limited a little; no, not

limited at all Question 4:

a. I

seem to get sick a little

easier than other

Doring the past 4 weeks,have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

Question 8: Duringthe past4 weeks, how.mochdid pain interferewith your normalwork (includingboth work outsidethe homeand housework)?

people b. I am as healthy as anybody I know c. I expect my health to get worse d. My health is excellent Scale: definitely true; mostly true; don't know; mostly false; definitely false

Tab. I: The SF-36 Health Survey for evaluating quality of life (German version).

Vertigoheel, manufactured by Biologische Heilmittel Heel GmbH of Baden-Baden, is a homeopathic medication containing the

(antivertigo neuroleptics,

drugs,

calcium

antagonists, (7-11).

sent paper study's the

is to convey the results of the assessments of Vertigoheel test. of qualand this aspect of

and placebos)

psychometric

ity of life and to investigate The results of the present published betahistine and intensity on assessing study were first performance in 1998 in a paper that focussed the effects of Vertigo heel and on the frequency, attacks duration, and only Methods of vertigo betahistine

ingredients Ambra 6X, Cocculus 4X, Conium 3X, and Petroleum 8X. Several studies have confirmed combination in treating drug the efficacy of this vertigos betahistine, served of varystudy, an H3

in a direct comparison

ing etiology (4-6, 12). In the present the anti vertigo receptor antagonist,

briefly discussed

the results of psychome-

Design of the Study For the purpose of daily comparison of the efficacy of Vertigo heel and beta his tine against vertigo over a treatment period of six weeks, the study was conceived as a multicentric, randomized, double-blind
3

as the refer-

ence substance. This drug has been widely tested in clinical studies; available data on it are abundant parisons and include reference direct com-

tric testing (12). For reasons mentioned above, however, a more detailed investigation particular of patients' subjective state of

health and the issue of quality of life is of interest. The purpose of the pre-

to other

substances

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QUALITY

OF LIFE

IN VERTIGO

PATIENTS:

A DOUBLE-BLIND

COMPARATIVE

STUDY

OF A HOMEOPATHIC

MEDICATION

Category I: direct symptoms

Question:

of vertigo

Category 3: symptoms associated

Question:

with vertigo

Category 4: limitations on. daily activities

Question: How true is each of the following statements about how you have been since your last visit? a. I was afraid of falling b. I was afraid that my illMSS would get worse c. I had trouble with fast movements d. I had trouble driving or using public trans. portation (bus/train) e. I had trouble getting up from a lying position f. I had trouble standing up from a sitting position

How would you rate the severity of the fonowing symptoms in any vertigo attacks you. had since your last visit? a. rotating sensation b. swaying sensation c. sensation of being elevated d. everything goes black e. everything gets blurry f. general unsteadiness g. distUrbed coordination Scale:

Since your last visit, how often have you experb enced the following symptoms in connection with attacks of vertigo? a. physical weaknessand exhaustion b. difficulty in seeing c. difficulty in hearing d. tinnitus e. headache f. g. h. i. j. palpitations trembling limbs gastrointestinal disturbances nausea a feeling of heavinessand pressurein your head gans general mental exhaustion light-headedness difficulty in concentrating restless sleep or insomnia nervousness

nonexistent;slight; moderate;severe;very severe Category 2: intensity of vertigo attacks cific activities

g. I had trouble. reading h. It was hard for me to climb stairs i. j. It was hard for me to go down.. stairs It was hard for me to move around in the dark

duringspe-

k. an empty feeling in various body parts or orI. m. n. o. p.

k. It was hard for me to leave the house/ apartment I. It was hard forme to look down m. It was hard for me to do housework Scale: not true at all; a little bit true; moderately true; mostly true; very true

Questiop: Since yourlast visit, howbad haveyour attacks of vertigobeenwhenyou a. turnedyour head? b. bentover? c. stoodup? d. lay down? Scale: seno sensation of vertigo;very mild;moderate; vere;very severe

q. fatigue r. forgetfulness s. anxiety Scale: never;seldom; sometimes; often;very often

Tab.2: Vertigo-specific questionnaire for evaluating quality of life

clinical sponding maintain

test

comparing

parallel

groups. to (for

the study.

The duration

of treatment

for

The double-dummy placebos

technique

with corre-

each patient of betahistine (12. The criteria were:

was six weeks; per day

the dosage see

German version has also performed well in terms of its scale structure and reliability in several series of tests on healthy and ill individuals. consists The SF-36 questionnaire and 36 subquesphysical funcroleof 11 questions

was implemented procedure

was 3x15 drops of Vertigo heel or 3x6 mg (for details,

the double-blind

details, see (12. Each patient kept a daily record of frequency, sity of vertigo primary life, each point rating attacks system. patient variables duration, using and intenthese of and assessed a four

tions in these 8 categories: targeted in assessing efficacy of tioning, role-physical, health, duration, and intensity vitality, social emotional,

bodily pain, general functioning,

or fiveSF-36

To assess quality completed the

. .

frequency,

and mental health (Table 1). scores for individual positive ques-

the vertigo attacks (patient diaries) vertigo-specific symptoms (vertigoWhere needed, uniformly specific questionnaire) quality of life (normed naire) general efficacy SF-36 questionby patients tions were transposed reflected so that high scores assessments

Health Survey and a vertigo-specific questionnaire (see Tables 1 and 2) on the first and last days of treatment Patient (visits 1 and 6).

Demographics of

ratings

of quality of life. Scores in each category were then totaled and converted into a score on a scale of a to 100 (converted score = 100 x [actual total score - lowest

Patients with acute or chronic vertigos

and physicians. Quality-of-Life The SF-36 Health for instrument This Questionnaire Survey is a general health-related (13). was the originally normed

varying etiology (including Meniere's disease and vasomotor disturbances) were included autonomic in the study. Excluded, with vertigo dysregulation, for examcaused by or con-

score] / range). sponds

Thus a score of a correof life and a quality of life. groups, for the

to the lowest quality of the two values were

ple, were patients

assessing test

score of 100 to the highest For each average

tumors,

quality of life; it is not illness-specific psychometric for use but developed countries,

treatment calculated

sumption of caffeine, nicotine, or alcohol. Concomitant treatment with other antivertigo

4

in English-speaking

drugs

was not permitted

during

meanwhile

total score in each category at visit 1 and visit 6 and for the difference between visit

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QUALITY

OF LIFE

IN VERTIGO

PATIENTS:

A DOUBLE-BLIND

COMPARATIVE

STUDY

OF A HOMEOPATHIC

MEDICATION

Vertigoheel
Category

VI 58.5

V6

Diff.

Statistics P<O.OOI 64.4 90.2

Diff. +25.8

Statistics P<O.OOI

I. Direct symptoms of vertigo

2. Intensity of vertigo attacks during specific activities 3. Symptomsassociated with vertigo

87.1 +28.6

Tab.3:Vertigo-specific questionnaire. VI = scoreat beginning of treatment; V6 '" scoreafter six weeksof treatment; Difl. = difference; Statistics: Wilcoxon-Pratt test (2-tailed)

53.6

82.9 +29.3

P<O.OOI

58.4

87.1

+ 28.7 P<O.OOI

65.2

84.2 + 19.0

P<O.OOI

72.8

89.6

+16.8

P<O.OOI

4. limitationson daily activities 47.9 59.7 +1 L8 P<O.OOI 49.7 62.2 + 12.5 P<O.OOI

6 and visit 1. In this scoring system, positive differences correspond to increases in quality of life. Mann-Whitney statistics and the left boundaries of the 90% confidence interval served as standards of releover

emotional

concomitant questions severity

phenomena

(Table

of the 90% confidence standards appearing of relevance

interval for

served

as

2). Individual and 4 great question.

were scored from a total absence in each individof the symptom

differences

0 to 4, with 0 representing After transposing

over the course of treatment. Results

vance for differences that appeared the course of treatment.

ual score (4 - original

score), total scores Vertigo Attacks In total, 119 patients group and from 15 licensed tions, cacy.) patients' evaluation duration, 14 of The (59 in the Vertigoheel group) particiwere of effiwere and 60 in the betahistine family practices 119 patients analysis groups

were calculated for each category and converted to a scale of 0 to 100 (converted score for The or

Vertigo-Specific This self-assessment the course evaluating

Questionnaire questionnaire of questions. contributing of the illness con-

[actual total score/highest

possi-

ble total score] x 100) for easier comparison. In each treatment group, average scores were calculated for each visit and for the difference between final and initial

pated in the study. (Due to protocol violathese excluded equivalent from statistical two medical revealed treatment histories. significant in terms

sists of four categories first category intensity of sensations

deals with the severity

to ver-

status (visit 6 and visit 1). In this scoring system, positive improvements Whitney statistics differences correspond to in health. Here, too, Mannand the left boundaries

tigo, the second with activities and the fourth with other

that trigger and

of demography

vertigo, the third with related symptoms, physical

Statistical and cliniattacks The in

cally relevant (the primary reductions

reductions

in the frequency, of vertigo

and intensity

SF.36Score 100
Physical Health

criteria) in both groups durtreatment period. equivalent were statistically

ing the six-week

80

the two groups (for details, see (12. Quality of Life data confirm

60

The recorded beginning experienced

that

at the had were

of treatment,

all patients

often considerable

declines in

40

their

quality

of life. Such declines

20

especially evident in the "vitality" and "role-emotional" areas (in the mental health summary measure) health and in the mearelethat by the
5

"role-physical" 0 BI A B6
BI B B6 Bt C B6 BI D B6

and "general health" areas summary and clinically

(in the physical vant reduction of duration,

sure). The significant

in vertigo attacks (in terms during was the six-week

intensity, and frequency) period groups. paralleled

Fig.I: Theinfluence of Vertigoheel and betahistine on quality of life (summary measure: physical health)in patients with vertigo. VI = initial score(beginning of treatment); V6 = final score(after six weeksof treatment); A = physical functioning; B = role-physical; ( = bodily pain;D = generalhealth.*Wilcoxon-Pratt test (2-tailed; P<O.OS)

was

documented

treatment improvement treatment

in quality

of life in both

Statistically,
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QUALITY

OF LIFE

IN VERTIGO

PATIENTS:

A DOUBLE.BLlND

COMPARATIVE

STUDY

OF A HOMEOPATHIC

MEDICATION

improvement

in quality of life was equivSf-36 Score 100 Mental Health symp-

alent in the two groups (Figures 1 and 2).

Vertigo-Specific In the psychometric toms, significant was and observed Questionnaire test of vertigo 80

improvement in both

in all items groups change in 60

treatment

corresponded of life. For

to positive example,

quality

subjective 40

vertigo-related gastrointestinal ness,

impairments symptoms, or

(palpitations, light-headeddisorders) both treatwere groups 0 81 A 86 81 8 86 81 ( 86 81 D 86 20

nervousness, significantly and the

sleep under

decreased ment

protocols, in

the

decreases

equivalent (Table 3).

two

treatment

Evaluation of Therapy Assessments of the efficacy of the therapies by both physicians roborated patients "very tests. A majority rated good" or and patients corthe results of the psychometric of the physicians freedom (= obvious improvement of the the
Fig. 2: The influence of Vertigoheel and betahistine on quality of life (summary measure:mental health) in patients with vertigo. VI = initial score (beginning of treatment); V6 = final score (after six weeks of treatment); A = vitality; B = role-emotional; C = social functioning; D = general mental health. 'Wilcoxon-Pratt test (2-tailed; P<O.OS)

and
as imwas from

the efficacy of therapy (= complete "good"

symptoms) provement). ratings, achieved patients patients in

and

corresponded quality

to improvements (severity

in

to implement help determine

psychometric

procedures

to

According 94%

to the physicians' Vertigo heel betahistine

health-related in individual vertigo and contributing toward

of life. The changes of the of sensations trends to

the need for suitable

ther-

symptomatic and

symptoms the intensity

apies and quantify (14).

the effects of therapies

83% of

to it) in the vertigo-specific significant The present study approaches the assesshealth. more they for scores. In some instances, amounted scores. scientific and guidequalment of quality The participating contented felt more capable ving, or moving without example, of life from the perspecand physical became patients

(for details, see (12) ).

Discussion

scoring system revealed higher the average to that A great effort applying deal has

improvements

tives of both mental

The purpose

of this study was to compare

nearly 50% of pretreatment

the efficacy of Vertigo heel (drops) of varying treatment mary intensity recorded Survey naire. served cal criteria etiology period. during

and took more initiative; of climbing about in the dark,

of betahistine in outpatients with vertigos

a six-week to the priand In addition

of concentrated into international

stairs, drito outsignifi-

gone standard

developing and assessing

fear or recourse They experienced

(frequency,

duration,

lines for documenting ity of life in individuals nesses. The example administered of the

side assistance.

of vertigo attacks) the study also the effect of therapy and a vertigo-specific anti vertigo drug on quality questionbeta his tine subtypiby the SF-36 Health

with specific illstudy involved very in

of the SF-36 survey both the immensity work to procedures assessing interhealthadefor

cantly fewer limitations on both domestic and recreational activities than at the beginning increased lems, their ized. of treatment, significantly. and their sense of various Because tasks well they felt prob-

of life as measured The

in the present

clearly demonstrates preparatory qualitative suited developing nationally related

being able to perform less constrained

as a recognized symptoms

reference and

by psychological

stance whose efficacy in suppressing vertigo patients' sense of well-being groups,

social behavior

also normal-

improving had already (7, 8, significant in verof

quality

of life and the substantial for methodologically of a test instrument

effort required quate conversion use in other international

been documented and clinically tigo attacks relevant

by clinical studies reductions

In a study of postcoronary rehabilitation demonstrated activation prognosis sions of quality phase, of social

patients Denollet

in the et al. and for

11). In both treatment relevant occurred

languages. Success on the level, however, facilitates

that social integration contacts, of life, are significant

over the course in subjective

the six-week treatment period. Clinically

reductions symptoms were also apparent
6

analysis of multinational clinical studies and research on international issues of health and health economics. In England,

as exprestwo to five

(15). In the first

in both groups

public health facilities have already begun

years after their heart attacks, the patients

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QUALITY

OF LIFE

IN VERTIGO

PATIENTS:

A DOUBLE-BLIND

COMPARATIVE

STUDY

OF A HOMEOPATHIC

MEDICATION

belonging

to Denollet's

Type D ("dis-

experimentellen Untersuchungen ("Biological treatment of vertigo with Vertigoheel: results of clinical experimental studies"). Bioi Med 1983; 12 (6): 531-2 (5) ClaussenCF,Bergmann J, Bertora G, ClaussenE. Klinisch-experimentelle Priifung und aquilibriometrische Messungenzum Nachweisder therapeutischenWirksamkeit eines homoopathischen Arzneimittels bestehend aus Ambra, Cocculus,Conium und Petroleum bei der DiagnoseVertigo und Nausea("Clinical experimental testing and equilibriometry prove the therapeutic efficacy of a homeopathic medication consisting of Ambra, Cocculus,Conium und Petroleum in cases of vertigo with nausea"). Arzneim-Forschl Drug Res 1984; 34: 1791-8 (6) Zenner S, Borho B, Metelmann H. Schwindel und seine BeeinfluBbarkeit durch ein homoopathischesKombinationspraparat ("The effects of a homeopathic combination medication on vertigo"). Erfahrungsheilkunde 1991;40 (6);423-9 (7) Elbaz P.Flunarizine and betahistine. Two different therapeutic approaches in vertigo compared in a double-blind study. Acta Octolaryngol Suppl 1988; 460; 143-8 (8) FraysseB, Bebear JP,Dubreuil C, et al. Betahistine dihydrochloride versus flunarizine. A double-blind study on recurrent vertigo with or without cochlear syndrome typical of Meniere'sdisease.Abstract Acta Otolaryngol 1991; 490 (Suppl.): 1-10 (9) KluyskensP,lambert P,D'Hooge D. Trimetazidine Versus Betahistine in Vestibular Vertigo. Double-blind Study. Drugs of Today 1990; 26 (Suppl 13): 13-22 (10) Canty P,Valentine J, Pap worth SJ.Betahistine in peri-

pheral vertigo. A double-blind, placebo-controlled, cross-over study of Serc@versus placebo.J laryngol Otol 1981; 95: 687-92 (II) Oosterveld WJ. Betahistine dihydrochloride in the treatment of vertigo of peripheral vestibular origin. A
double-blind placebo controlled study.

tressed personality"), ation, had a mortality

which is characterrate four times that

ized by severe depression and social alienof the patient group as a whole. In summary, study the results of the present that treating vertigo and

J laryngol

Otol

1984; 98: 37-41 (12) Weiser M, StrosserW, Klein P. Homeopathic vs Conventional Treatment of Vertigo - A Randomized Doubleblind Controlled Clinical Study. Arch Otolaryngol Head Neck Surg 1998; 124: 879-85 (13) Ware JE, Kosinski M, Keller SD.SF-36 Physical and Mental Health Summary Scales: A User's Manual.The Health Institute, New England Medical Center, Boston, MassachusettsDecember, 1994 (14) Bullinger M, Kirchberger I, Ware J. Der deutsche SF-36 Health Survey ("The German SF-36 Health Survey"). Z Gesundheitswiss1995; 3: 21-36 (15) Denollet J, Sys SU,Stroobant N, et al. Personality as independent predictor of long-term mortality in patients with coronary heart disease.lancet 1996; 347: 417-21

demonstrate

patients with Vertigo heel produces obvious improvement in both physical mental health (as expressions of quality of life) and that the effects of Vertigo heel are comparable to those of betahistine. apy is confirmed.
References (I) Kroenke K,Arrington ME,MangelsdorffAD.The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med 1990; 150: 1685-9 (2) Stoll W. Sinnvolle Diagnostik und Therapie des Symptoms Schwindel("Meaningful diagnosis and therapy of symptomatic vertigo"). Dtsch Arztebl 1996; 93: A-460-4 (3) Hlatky MA. Patient preferences and clinical guidelines. JAMA 1995; 273; 1219-20 (4) ClaussenCF.Der Schwindel und seine biologische Behandlung mit Vertigoheel Ergebnissevon klinisch

Fur-

thermore, the safety of both forms of ther-

Authors' address: c/o Dr. Michael Weiser Gleisslestr. 77815 Biihl Germany 34

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E129 (D-) /2/2001

KK
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