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Dear All:
thanks a lot to those who replied to my
question reported here below on the assessment of
the level of activity. the detailed list of
replies is attached as usual. In brief summary,
it appears there is too little or too much,
depending how you see it. It seems nothing is
exactly what I was looking for, but there is a
lot of stuff (maybe too much) with similar
purposes.
A very specific questionnaire is the Hip Outcome
Score(HOS). unfortunately, it does not try to
assess the frequency of the most sever loading
conditions. but only if the patient can perform
them.
Some suggest to use a wearable monitor instead of
questionnaire. Being an engineer I do not need
to be convinced that measurements are always
better than opinions, whenever possible.
However, the organizational impact of
questionnaires is minimal compared to wearable
monitors, so I guess the comparison is unfair.
Cheers
Marco
***********ORIGINAL QUESTION********
In the orthopaedics clinical practice it is
common to assess the health status and the
clinical outcome of certain procedures such as
joint replacement by means of questionnaires to
be filled by the doctor or by the patient
directly. Typical examples are the Harris hip
score or the Womac.
many of these questionnaires have questions
related to the physical activity of the patient,
but all aims to assess the level of disability
the patient is experiencing, through questions
such as "are you able to climb a fly of stairs?".
While this is perfectly appropriate for elder
patients, the indications of joint replacements
are constantly expanding, and we are now dealing
with younger patients, many of which return to a
physically active life after the operation. This
opens new scenarios for the biomechanics research
of prosthetic devices, which are now exposed to
much heavier load histories than in less active
patients. It is thus essential to assess,
possibly with a questionnaire, if the patient
enjoys a physically active life, and and how
intensive is the loading he or she impose to the
prosthetic joint.
Is anybody aware if there is a questionnaire
already validated that aims to assess the level
of activity, rather than the level of disability,
even in slightly different clinical contexts?
If nothing is already available, do you think it
would make sense to try to develop and validate
one, possibly through a consensus process within
our community?
********REPLIES*******
-------------------------------------------------------
You may want to look at the International Physical Activity Questionnaire.
http://www.ipaq.ki.se/
It has several questions to get at overall
physical activity, has been validated, and comes
in several languages. I am planning on using this
instrument for a study I am conducting, but have
not done so yet. If you find a better one, please
let me know. Thank you, laura
Laura Frey Law, PT, PhD
Assistant Professor
Physical Therapy and Rehabilitation Science The University of Iowa
1-252 Medical Education Bldg
Iowa City, IA 52242
(319) 335-9804
-------------------------------------------------------
Marco,
Instead of a questionnaire, it might be
beneficial to measure the activity level.
Attached is a study describing an activity
monitor. They're really easy to use, and tough
for patients to give misleading results.
Coleman KL, Smith DG, Boone DA, Joseph AW, del Aguila MA.
Step activity monitor: long-term, continuous recording of ambulatory function.
J Rehabil Res Dev. 1999 Jan;36(1):8-18.
Best of luck,
Brian
Brian Glaister
Research Assistant
University of Washington Department of Mechanical Engineering
and
Center of Excellence for Limb Loss Prevention and
Prosthetic Engineering VA Puget Sound Health Care
System
--------------------------------------------------
I have developed a questionnaire that assesses
higher level activity for individuals with
musculoskeletal related hip pathology: The Hip
Outcome Score(HOS).
We have evidence of validity based on its
relation to the SF-36 and are currently analyzing
data related to responsiveness and test retest
reliability.
It can currently be found at:
http://www.healthsciences.duq.edu/faculty/martin.html
References are as follows:
Schenker ML, Martin RL, Weiland DE, Philippon MJ:
Current trends in hip arthroscopy: A review of
injury diagnosis, surgical techniques, and
outcome scoring. Current Opinion in Orthopaedics.
16: 89-94: 2005.
Martin RL. Hip arthroscopy and outcome
assessment. Operative Techniques in Orthopaedics.
15(3): 290-296:2005.
Martin RL, Kelly BT, Philippon MJ. Evidence of
validity for the Hip Outcome Score(HOS). Journal
of Orthopaedic Sports Physical Therapy.35; A18:
2005.
Please do not hesitate to contact me with further questions.
RobRoy Martin PhD, PT, CSCS
Duquesne University
Department of Physical Therapy
114 Rangos School of Health Sciences
Pittsburgh, PA 15282
412-396-1811
(fax)412-396-4399
martinr280@duq.edu
--------------------------------------------------
Hi Marco
I'm a physiotherapist working on rehabilitation
following articular cartilage repair and I'm just
starting a PhD looking at return to sport and
exercise activities following ACI cartilage
repair procedures so I've been looking at the
outcomes measures as well. You should find the
following of interest -
http://www.koos.nu/
http://www.cincinnatisportsmed.com/puba.htm
http://www.cartilage.org/files/ICRS_evaluation.pdf
Published studies on cartilage repair procedures
commonly present outcomes in terms of a measure
of change from preoperative status to a
chronological endpoint, as opposed to individual
goal achievement. I think this is an issue with a
lot of the questionnaire outcome measures.
I'd be very interested to hear what responses you
have and how you decided to proceed.
Regards
Karen
Karen Hambly
Senior Lecturer - Sports Therapy London
Metropolitan University 166-220 Holloway Road
London
N7 8DB karen@rehabmatters.com tel:
mobile: 0207 133 2274
07709 581265
--------------------------------------------------
Marco,
There was a Supplement of Medicine and Science in
Sport and Exercise (Vol 29, No. 6 June 1997) that
compiled Physical Activity Questionnaires for
health related research, as of that date.
Gordon Chalmers, Ph.D.
Dept. of Physical Education, Health and
Recreation Western Washington University
516 High St.
Bellingham, WA, U.S.A.
98225-9067
http://www.ac.wwu.edu/~chalmers/
Phone: 360-650-3113
Email: Gordon-dot-Chalmers-at-wwu-dot-edu
in above email address: replace "-dot-" with "."
replace "-at-" with "@"
--------------------------------------------------
Ciao Marco,
hai già provato il Tegner score che si usa per
ACL reconstruction? Magari si può adattare
all'anca o dare idee su i livelli di prestazioni
e l'attività propriocettiva. Ciao, sandra
Sandra Martelli
--------------------------------------------------
Hi Marco,
this has always been a problem with clinical
quesitonnaires and is a reason why we have been
developing objective functional measurements and
classification systems.
This is also compounded by the fact that
"recovered" younger hip/knee replacement patients
equate more to normal joint function compared to
elderly outcomes. So the new designs of knee that
are supposed to bring more natural knee function
apply to these people also.
We have talked to various people about combining
objective functional classifiers with subjective
clinical and patient-led questionnaires and it is
viewed as a useful marriage of information.
Lets see if anyone has a useful questionnaire and
as you know I am very keen to develop community
approaches to joint function classification using
collaborative-cohorts of data.
Cheers
Cathy
Dr Cathy Holt
Lecturer in Biomechanics
School of Engineering
Cardiff University
Queen's Buildings
The Parade
Cardiff CF24 3AA
Wales
UK
tel 00 44 0(29) 2087 4533
fax 00 44 0(29) 2087 4939
http://www.engin.cf.ac.uk/whoswho/profile.asp?RecordNo=198
--------------------------------------------------
Hi
An excellent one designed and validated for
children (who are also very active!) is the
Activity Scale for Kids (ASK), by Dr. Nancy Young
at the Hospital for Sick Children
(nancy.young@sickkids.ca). It has been used with
several different populations of kids. It might
be a good starting point for developing an adult
version.
Development/validation of a questionnaire can
take a couple of years - i think the community
could contribute, but a single group would need
to take the lead to get the validation done.
Best of luck,
Sheila Purkiss
--------------------------------------------------
I used what I called a modified activity
questionnaire in my dissertation which took
scales from 2 or 3 established questionnaires in
an attempt to quantify individual and team
sporting activities.
In the attached word document I copied some
statements and tables from a paper in review with
Journal of Motor Behavior and then copied the
appendix containing the activity questionnaire
from my dissertation.
Paper is: Roncesvalles MN, Woollacott MH, Brown
N, Jensen JL. An emerging postural response: is
control of the hip possible in the newly walking
child?
J Mot Behav. 2004 Jun;36(2):147-59.
Please let me know if you have further question about this information.
Regards
Nick
----------------------
Nicholas Brown, Ph.D.
Research Assistant Professor
University of Utah
Department of Orthopaedics
590 Wakara Way, Room A100
Salt Lake City, UT. 84105
(801) 587-5200 (phone)
(801) 587-5211 (fax)
Nick.Brown@hsc.utah.edu
--------------------------------------------------
From: Don Hoover
Marco,
Let me suggest a couple of resources containing a
number of instruments that may be of use for you
in this regard: Finch E, Brooks D, Stratford PW,
Mayo NE. /Physical Rehabilitation Outcome
Measures: A Guide to Clinical Decision Making
(2^nd ed.)./ Hamilton, Ontario: Canadian
Physiotherapy Association, 2002.
Suk M, Hanson BP, Norvell DC, Helfet DL.
/Musculoskeletal Outcomes Measures and
Instruments./ New York: AO Publishing/Thieme,
2005.
Also, Medicine and Science in Sports and Exercise
published a compendium of such instruments in the
late 1990s: I don't have the exact citation this
but I think it was published as an Appendix.
Hope all this helps,
Don
--------------------------------------------------
Ciao Marco,
Have you taken a look at David Johnson's 2001
paper in The Knee titled "Outcome measurement in
the ACL deficient knee - What's the score?"
(Johnson, D. S. and R. B. Smith (2001). "Outcome
measurement in the ACL deficient knee : what's
the score?" Knee 8(1): 51-57.) It may point in in
the right direction.
Cheers,
Chris
Chris Dyrby, Eng. Research Engineer
Department of Mechanical Engineering
Stanford University
Durand Bldg Rm 061C
Stanford, CA 94305-4038
Ph: (650) 723-5793
Fax: (650) 725-1587
--------------------------------------------------
Marco, assessing patient physical activity from
questionaiires is fraught with difficluty and it
would be ideal to determine activity accurately
(pedometers/data loggers etc.) with these
patients.
You will be aware of the work of Schmalzried et
al which assesed the activity level of patients
with THR and TKR using pedometers.
Silva M, Shepherd EF, Jackson WO, Dorey FJ,
Schmalzried TP. Average patient walking activity
approaches 2 million cycles per year: pedometers
under-record walking activity. J Arthroplasty.
2002 Sep;17(6):693-7.
Weekly data was extrapolated to determine the
yearly cycle rate of the patients. Prosthetic
manufacturers use 1 million cycles per year for
simulator studies.
However, although the Harris/Oxford/WOMAC hip
scores are all validated, it may not be accurate
to infer a subjects activity level from a
questionairre (see ref below)
Kennedy D, Stratford PW, Paguara SM, Walsh M,
Woodhouse LJ. Comparison of gender and group
differences in self-report and physical
performance measures in total hip and knee
arthroplasty candidates. J Arthroplasty
2002;17:70-7.
We have compared the reuslts of post-op patient
activity sections of the hip scores with walking
test results and found poor results, so there may
be a better way of doing this.
Best of luck with the work!
Damien Bennett, PhD
Bioengineer,
Gait Lab,
Central Remedial Clinic,
Vernon Avenue,
Clontarf,
Dublin 3,
Ireland.
e-mail: dbennett@crc.ie
Phone: 00353 1 8057531
FAX: 00353 1 8057570
--------------------------------------------------
Dear Marco,
A collegue forwarded your Biomch-L mail to me
about questionnaires measuring level of activity.
As far as I know, no questionnaires exist that
validly measure level of activity. In a study in
orthopedic patients we use the PASIPD, but this
list is far from optimal. In that study, we also
perform ambulatory measurements with an Activity
Monitor (search e.g. at Bussmann JB at PubMed);
these types of instruments are a valuable tool in
assessing daily physical activity.
Regards,
Hans Bussmann
J.B.J. Bussmann, PT PhD
Senior researcher Dept. of Rehabilitation
Medicine Erasmus MC - University Medical Centre
Rotterdam PO Box 2040, 3000 CA Rotterdam, The
Netherlands phone: +31-10-4633906/3190
fax: +31-10-4633843
--
--------------------------------------------------
MARCO VICECONTI, PhD (viceconti@tecno.ior.it)
Laboratorio di Tecnologia Medica tel. 39-051-6366865
Istituti Ortopedici Rizzoli fax. 39-051-6366863
via di barbiano 1/10, 40136 - Bologna, Italy
Tiger! Tiger! Burning bright in the forest of the night,
what immortal hand or eye could frame thy fearful symmetry?
--------------------------------------------------
Opinions expressed here do not necessarily reflect those of my employer
thanks a lot to those who replied to my
question reported here below on the assessment of
the level of activity. the detailed list of
replies is attached as usual. In brief summary,
it appears there is too little or too much,
depending how you see it. It seems nothing is
exactly what I was looking for, but there is a
lot of stuff (maybe too much) with similar
purposes.
A very specific questionnaire is the Hip Outcome
Score(HOS). unfortunately, it does not try to
assess the frequency of the most sever loading
conditions. but only if the patient can perform
them.
Some suggest to use a wearable monitor instead of
questionnaire. Being an engineer I do not need
to be convinced that measurements are always
better than opinions, whenever possible.
However, the organizational impact of
questionnaires is minimal compared to wearable
monitors, so I guess the comparison is unfair.
Cheers
Marco
***********ORIGINAL QUESTION********
In the orthopaedics clinical practice it is
common to assess the health status and the
clinical outcome of certain procedures such as
joint replacement by means of questionnaires to
be filled by the doctor or by the patient
directly. Typical examples are the Harris hip
score or the Womac.
many of these questionnaires have questions
related to the physical activity of the patient,
but all aims to assess the level of disability
the patient is experiencing, through questions
such as "are you able to climb a fly of stairs?".
While this is perfectly appropriate for elder
patients, the indications of joint replacements
are constantly expanding, and we are now dealing
with younger patients, many of which return to a
physically active life after the operation. This
opens new scenarios for the biomechanics research
of prosthetic devices, which are now exposed to
much heavier load histories than in less active
patients. It is thus essential to assess,
possibly with a questionnaire, if the patient
enjoys a physically active life, and and how
intensive is the loading he or she impose to the
prosthetic joint.
Is anybody aware if there is a questionnaire
already validated that aims to assess the level
of activity, rather than the level of disability,
even in slightly different clinical contexts?
If nothing is already available, do you think it
would make sense to try to develop and validate
one, possibly through a consensus process within
our community?
********REPLIES*******
-------------------------------------------------------
You may want to look at the International Physical Activity Questionnaire.
http://www.ipaq.ki.se/
It has several questions to get at overall
physical activity, has been validated, and comes
in several languages. I am planning on using this
instrument for a study I am conducting, but have
not done so yet. If you find a better one, please
let me know. Thank you, laura
Laura Frey Law, PT, PhD
Assistant Professor
Physical Therapy and Rehabilitation Science The University of Iowa
1-252 Medical Education Bldg
Iowa City, IA 52242
(319) 335-9804
-------------------------------------------------------
Marco,
Instead of a questionnaire, it might be
beneficial to measure the activity level.
Attached is a study describing an activity
monitor. They're really easy to use, and tough
for patients to give misleading results.
Coleman KL, Smith DG, Boone DA, Joseph AW, del Aguila MA.
Step activity monitor: long-term, continuous recording of ambulatory function.
J Rehabil Res Dev. 1999 Jan;36(1):8-18.
Best of luck,
Brian
Brian Glaister
Research Assistant
University of Washington Department of Mechanical Engineering
and
Center of Excellence for Limb Loss Prevention and
Prosthetic Engineering VA Puget Sound Health Care
System
--------------------------------------------------
I have developed a questionnaire that assesses
higher level activity for individuals with
musculoskeletal related hip pathology: The Hip
Outcome Score(HOS).
We have evidence of validity based on its
relation to the SF-36 and are currently analyzing
data related to responsiveness and test retest
reliability.
It can currently be found at:
http://www.healthsciences.duq.edu/faculty/martin.html
References are as follows:
Schenker ML, Martin RL, Weiland DE, Philippon MJ:
Current trends in hip arthroscopy: A review of
injury diagnosis, surgical techniques, and
outcome scoring. Current Opinion in Orthopaedics.
16: 89-94: 2005.
Martin RL. Hip arthroscopy and outcome
assessment. Operative Techniques in Orthopaedics.
15(3): 290-296:2005.
Martin RL, Kelly BT, Philippon MJ. Evidence of
validity for the Hip Outcome Score(HOS). Journal
of Orthopaedic Sports Physical Therapy.35; A18:
2005.
Please do not hesitate to contact me with further questions.
RobRoy Martin PhD, PT, CSCS
Duquesne University
Department of Physical Therapy
114 Rangos School of Health Sciences
Pittsburgh, PA 15282
412-396-1811
(fax)412-396-4399
martinr280@duq.edu
--------------------------------------------------
Hi Marco
I'm a physiotherapist working on rehabilitation
following articular cartilage repair and I'm just
starting a PhD looking at return to sport and
exercise activities following ACI cartilage
repair procedures so I've been looking at the
outcomes measures as well. You should find the
following of interest -
http://www.koos.nu/
http://www.cincinnatisportsmed.com/puba.htm
http://www.cartilage.org/files/ICRS_evaluation.pdf
Published studies on cartilage repair procedures
commonly present outcomes in terms of a measure
of change from preoperative status to a
chronological endpoint, as opposed to individual
goal achievement. I think this is an issue with a
lot of the questionnaire outcome measures.
I'd be very interested to hear what responses you
have and how you decided to proceed.
Regards
Karen
Karen Hambly
Senior Lecturer - Sports Therapy London
Metropolitan University 166-220 Holloway Road
London
N7 8DB karen@rehabmatters.com tel:
mobile: 0207 133 2274
07709 581265
--------------------------------------------------
Marco,
There was a Supplement of Medicine and Science in
Sport and Exercise (Vol 29, No. 6 June 1997) that
compiled Physical Activity Questionnaires for
health related research, as of that date.
Gordon Chalmers, Ph.D.
Dept. of Physical Education, Health and
Recreation Western Washington University
516 High St.
Bellingham, WA, U.S.A.
98225-9067
http://www.ac.wwu.edu/~chalmers/
Phone: 360-650-3113
Email: Gordon-dot-Chalmers-at-wwu-dot-edu
in above email address: replace "-dot-" with "."
replace "-at-" with "@"
--------------------------------------------------
Ciao Marco,
hai già provato il Tegner score che si usa per
ACL reconstruction? Magari si può adattare
all'anca o dare idee su i livelli di prestazioni
e l'attività propriocettiva. Ciao, sandra
Sandra Martelli
--------------------------------------------------
Hi Marco,
this has always been a problem with clinical
quesitonnaires and is a reason why we have been
developing objective functional measurements and
classification systems.
This is also compounded by the fact that
"recovered" younger hip/knee replacement patients
equate more to normal joint function compared to
elderly outcomes. So the new designs of knee that
are supposed to bring more natural knee function
apply to these people also.
We have talked to various people about combining
objective functional classifiers with subjective
clinical and patient-led questionnaires and it is
viewed as a useful marriage of information.
Lets see if anyone has a useful questionnaire and
as you know I am very keen to develop community
approaches to joint function classification using
collaborative-cohorts of data.
Cheers
Cathy
Dr Cathy Holt
Lecturer in Biomechanics
School of Engineering
Cardiff University
Queen's Buildings
The Parade
Cardiff CF24 3AA
Wales
UK
tel 00 44 0(29) 2087 4533
fax 00 44 0(29) 2087 4939
http://www.engin.cf.ac.uk/whoswho/profile.asp?RecordNo=198
--------------------------------------------------
Hi
An excellent one designed and validated for
children (who are also very active!) is the
Activity Scale for Kids (ASK), by Dr. Nancy Young
at the Hospital for Sick Children
(nancy.young@sickkids.ca). It has been used with
several different populations of kids. It might
be a good starting point for developing an adult
version.
Development/validation of a questionnaire can
take a couple of years - i think the community
could contribute, but a single group would need
to take the lead to get the validation done.
Best of luck,
Sheila Purkiss
--------------------------------------------------
I used what I called a modified activity
questionnaire in my dissertation which took
scales from 2 or 3 established questionnaires in
an attempt to quantify individual and team
sporting activities.
In the attached word document I copied some
statements and tables from a paper in review with
Journal of Motor Behavior and then copied the
appendix containing the activity questionnaire
from my dissertation.
Paper is: Roncesvalles MN, Woollacott MH, Brown
N, Jensen JL. An emerging postural response: is
control of the hip possible in the newly walking
child?
J Mot Behav. 2004 Jun;36(2):147-59.
Please let me know if you have further question about this information.
Regards
Nick
----------------------
Nicholas Brown, Ph.D.
Research Assistant Professor
University of Utah
Department of Orthopaedics
590 Wakara Way, Room A100
Salt Lake City, UT. 84105
(801) 587-5200 (phone)
(801) 587-5211 (fax)
Nick.Brown@hsc.utah.edu
--------------------------------------------------
From: Don Hoover
Marco,
Let me suggest a couple of resources containing a
number of instruments that may be of use for you
in this regard: Finch E, Brooks D, Stratford PW,
Mayo NE. /Physical Rehabilitation Outcome
Measures: A Guide to Clinical Decision Making
(2^nd ed.)./ Hamilton, Ontario: Canadian
Physiotherapy Association, 2002.
Suk M, Hanson BP, Norvell DC, Helfet DL.
/Musculoskeletal Outcomes Measures and
Instruments./ New York: AO Publishing/Thieme,
2005.
Also, Medicine and Science in Sports and Exercise
published a compendium of such instruments in the
late 1990s: I don't have the exact citation this
but I think it was published as an Appendix.
Hope all this helps,
Don
--------------------------------------------------
Ciao Marco,
Have you taken a look at David Johnson's 2001
paper in The Knee titled "Outcome measurement in
the ACL deficient knee - What's the score?"
(Johnson, D. S. and R. B. Smith (2001). "Outcome
measurement in the ACL deficient knee : what's
the score?" Knee 8(1): 51-57.) It may point in in
the right direction.
Cheers,
Chris
Chris Dyrby, Eng. Research Engineer
Department of Mechanical Engineering
Stanford University
Durand Bldg Rm 061C
Stanford, CA 94305-4038
Ph: (650) 723-5793
Fax: (650) 725-1587
--------------------------------------------------
Marco, assessing patient physical activity from
questionaiires is fraught with difficluty and it
would be ideal to determine activity accurately
(pedometers/data loggers etc.) with these
patients.
You will be aware of the work of Schmalzried et
al which assesed the activity level of patients
with THR and TKR using pedometers.
Silva M, Shepherd EF, Jackson WO, Dorey FJ,
Schmalzried TP. Average patient walking activity
approaches 2 million cycles per year: pedometers
under-record walking activity. J Arthroplasty.
2002 Sep;17(6):693-7.
Weekly data was extrapolated to determine the
yearly cycle rate of the patients. Prosthetic
manufacturers use 1 million cycles per year for
simulator studies.
However, although the Harris/Oxford/WOMAC hip
scores are all validated, it may not be accurate
to infer a subjects activity level from a
questionairre (see ref below)
Kennedy D, Stratford PW, Paguara SM, Walsh M,
Woodhouse LJ. Comparison of gender and group
differences in self-report and physical
performance measures in total hip and knee
arthroplasty candidates. J Arthroplasty
2002;17:70-7.
We have compared the reuslts of post-op patient
activity sections of the hip scores with walking
test results and found poor results, so there may
be a better way of doing this.
Best of luck with the work!
Damien Bennett, PhD
Bioengineer,
Gait Lab,
Central Remedial Clinic,
Vernon Avenue,
Clontarf,
Dublin 3,
Ireland.
e-mail: dbennett@crc.ie
Phone: 00353 1 8057531
FAX: 00353 1 8057570
--------------------------------------------------
Dear Marco,
A collegue forwarded your Biomch-L mail to me
about questionnaires measuring level of activity.
As far as I know, no questionnaires exist that
validly measure level of activity. In a study in
orthopedic patients we use the PASIPD, but this
list is far from optimal. In that study, we also
perform ambulatory measurements with an Activity
Monitor (search e.g. at Bussmann JB at PubMed);
these types of instruments are a valuable tool in
assessing daily physical activity.
Regards,
Hans Bussmann
J.B.J. Bussmann, PT PhD
Senior researcher Dept. of Rehabilitation
Medicine Erasmus MC - University Medical Centre
Rotterdam PO Box 2040, 3000 CA Rotterdam, The
Netherlands phone: +31-10-4633906/3190
fax: +31-10-4633843
--
--------------------------------------------------
MARCO VICECONTI, PhD (viceconti@tecno.ior.it)
Laboratorio di Tecnologia Medica tel. 39-051-6366865
Istituti Ortopedici Rizzoli fax. 39-051-6366863
via di barbiano 1/10, 40136 - Bologna, Italy
Tiger! Tiger! Burning bright in the forest of the night,
what immortal hand or eye could frame thy fearful symmetry?
--------------------------------------------------
Opinions expressed here do not necessarily reflect those of my employer