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Category: Health and Wellness

  • Three factors that impact backpack safety

    It’s that time of year again. You’re counting the days until your child heads back to school. However, before you put them on the bus, you’ll need to make sure they have everything they need for school, and this may include making sure they have the safest possible backpack. Here are three factors you should consider when making sure a backpack is safe for your child: 

    1. Size

    Backpacks, like children, come in all shapes and sizes, and the size of the backpack is one factor to consider when buying your child a new one. For instance, the bag you choose shouldn’t reach much higher than the child’s shoulders. If it goes higher than this, it could cause them to bend forward too much when carrying it. 

    As for the bottom of the backpack, it should rest comfortably in the curve of the lower back. This is because a bag that sags down lower can cause the spine to curve backward too much, and this can lead to other posture-related issues for your child. 

    1.   Fit

    You may be tempted to make a too small backpack last longer or purchase one a little too large for longer-lasting fit. However, a backpack that fits properly is much safer. 

    One characteristic of a safe backpack is well-fitting shoulder straps – they should rest comfortably on the shoulders. They should also allow children to move their arms freely while wearing the backpack. Having a waist strap that fits your child can also help make a backpack safer. This is because waist straps help hold the pack closer to the body, and they also transfer some of the bag’s weight to the hips instead of the spine. 

    1.   Weight

    Many kids tend to load up their backpack with far too much. It’s important to teach your child how much weight they should limit in their backpack. The idea is that they shouldn’t be carrying more than about 10% of their body weight, and you can do a simple exercise with them, so they know what this feels like. 

    For example, a child weighing 86 pounds shouldn’t be carrying more than about 8.6 pounds in their backpack. This is about how much a gallon of milk weighs. Simply place a full gallon of milk in your child’s backpack and have them put it on. This will give them a reference for the most weight they should be carrying in their bag. For heavier children, you could use other common objects like hand weights to achieve the same goal. 

    Armor Physical Therapy can help make it safer for your child to carry a backpack

    At Armor Physical Therapy, we want to help you keep your child safe when they’re carrying a backpack. One way we can increase their safety is by helping to address posture issues. We can also help treat muscle imbalances and medical conditions that can make it less safe to carry a backpack. You can even download our backpack report card to make sure your child’s backpack is the safest possible one for them. 

    Contact us today to find out more about backpack safety or to schedule a backpack fitting.

  • Three tips for better sleep with whiplash in Wentzville, MO

    Three tips for better sleep with whiplash in Wentzville, MO

    Whiplash is an injury that often occurs to the neck or back during a motor vehicle accident. This condition can cause you to experience pain, and it can also lead to tense back, shoulder and neck muscles. One issue that you may have when dealing with whiplash is that it makes it harder for you to sleep well at night. If you’re having trouble sleeping with whiplash in Wentzville, Missouri, there are three tips that may help you sleep better. 

    1.   Check your sleeping position

    You may want to make some changes to your sleeping position if you have whiplash. For one thing, it’s better for whiplash patients to sleep on their side or back. However, you’ll want to make sure that your head and neck are in a neutral position regardless of which sleeping position you prefer. 

    Also, using a pillow between your knees when sleeping on your side can help decrease pressure on your neck and spine. Patients who prefer to sleep on their back can get the same benefit by placing a pillow under their knees. These changes to your sleeping position can help you sleep a lot better while recovering from whiplash. 

    2.   Relax before getting in bed

    The tense muscles that whiplash can cause may increase your pain and make it harder for you to sleep. One tip to counteract this muscle tenseness is to find ways to relax before you go to bed. For example, taking a warm shower or bath can help reduce the tension in your muscles. 

    It may also help to perform some gentle stretches before getting in bed, and a physical therapist can help you develop an at-home stretching plan to use before bed. Also, you can try doing some breathing exercises to reduce both physical and mental tension right before bed. The sense of relaxation that these activities can bring can be helpful in getting a better night’s sleep with whiplash. 

    3.   Do some gentle physical activity during the day

    It’s true that you’ll need to take some time to rest when you first get whiplash, but after a few days, doing some gentle physical activity can be helpful. For instance, you can talk a short walk a few times a day. Gentle activity such as this can be especially helpful for getting to sleep. This is because even gentle physical activity can help tire you out. 

    Gentle activities can also have other benefits for whiplash. Activity helps improve the blood flow to the neck. This allows more oxygen and nutrients to get to your injury, and in turn, more oxygen and nutrients can help improve your body’s natural healing ability while you’re sleeping. 

    Excel Sports & Physical Therapy wants to help treat your whiplash

    At Excel Sports & Physical Therapy, we’re ready to help you treat many motor vehicle accident injuries such as whiplash. Our Wentzville clinic has a highly trained team of physical therapists that can offer you support during your recovery, and part of this support will be the personalized treatment plan we create for you. We’ll also be here to provide encouragement throughout your entire recovery process. 

    Take the next step to get our support for your injury recovery. Contact our team today for more information or to schedule an appointment. 

  • Three benefits of doing Pilates once a week

    Three benefits of doing Pilates once a week

    When most people think of exercising, their minds probably turn to fast-paced exercises like running or high-intensity weight training. However, you’d be surprised how many benefits you can get from slower-paced exercises like Pilates. Pilates routines use more than 500 exercises that come from disciplines like yoga and ballet, and the fact that there are so many movements to choose from is one reason it offers so many benefits. Here are three of the benefits you could get just by doing Pilates once a week. 

    1.   Improved flexibility

    Many of us remember being able to touch our toes as a kid, and this level of flexibility may be something that you look back on with nostalgia. One amazing benefit of Pilates is that you can improve your flexibility greatly with just one session a week. 

    Flexibility is all about keeping the muscles loose and limber, but many people tend to skimp on their stretches even when they work out regularly. Doing Pilates one day a week can help get you back in the habit of stretching, and it can help teach you stretches and flexibility exercises that directly target your specific flexibility issues. 

    2.   Increased core muscle strength

    The core muscles are those in your stomach, sides, back and pelvic floor, and in many people, these muscles are far weaker than they should be. This is a serious issue because the core muscles help with vital tasks like supporting the spine and allowing you to maintain a healthy posture. 

    With a once-a-week Pilates session, you can benefit from movements that help increase the strength of core muscles. These movements are usually gentle and place low levels of stress on the body, and this means they can be used by beginners, arthritis sufferers and other people who can’t do more vigorous, high-impact core exercises. By using Pilates to increase core strength, you can also improve posture and reduce stress on your spine and joints. 

    3.   Clear your mind

    Remember in The Matrix when Neo was told, “Free your mind”? Well, that’s actually another benefit that using Pilates once a week can offer. You won’t be able to slow time or anything, but Pilates can help you deal with the mental stress many of us deal with every day. Mental stress is an issue because it can lead to other mental issues like depression, but it can also affect you physically.

    Stress causes your body to release a hormone called cortisol, and having high cortisol levels in your body for long periods of time can increase your risk of heart disease, obesity and other physical problems. The slow, meditative movements of Pilates can help you let go of your mental stress and free your mind and body from the negative effects of high cortisol. 

    SOL Physical Therapy offers you the opportunity to try once-a-week Pilates

    At SOL Physical Therapy, we offer many types of physical therapy, and this includes having physical therapists that are also Pilates instructors. You can come see us once a week and work through a Pilates routine designed to: 

    • Improve flexibility
    • Increase core strength
    • Reduce mental stress
    • Improve muscle balance

    You can even get these benefits more rapidly by scheduling more than one Pilates session a week. 

    Get started with your Pilates session at SOL Physical Therapy today. Contact our team for more information or to schedule an appointment. 

  • How to find TMJ pain relief

    We often don’t think about our jaw, until it starts to hurt. That clicking sound while chewing may be a symptom of an underlying problem. An earache or headache may be originating from your temporomandibular joint (TMJ). If you are experiencing pain in the jaw, jaw popping, headaches, sore jaw muscles, locking of the jaw, and/or pain in the temple and earache, it is important to see a physician to rule out any underlying medical problems. Once it is determined to be TMJ disorder, your dentist and physical therapists can help create an effective treatment.

    But how can you find TMJ pain relief today?

    TMJ pain relief at home

    To relieve TMJ pain, start with relaxation techniques. Often tension that forms in our jaw is due to life stresses. Practice deep, slow breathing. Spend time in meditation and learn to relax your facial muscles. This video shows you a simple technique to manually manipulate the muscles of your jaw. Make a conscious effort to not clench your jaw when dealing with stressful situations.

    You also need to avoid crunchy and chewy food. Instead, reach for soft foods that give your jaw a rest. Stay away from the popcorn, chewing gum and apples for now. Puddings, soups and smoothies make great alternatives.

    Reduce pain with heat or ice. Wrap a hot water bottle in a moist towel and hold it on your jaw but be careful not to burn yourself. The same with ice. An ice pack can numb the pain and decrease any swelling, but don’t put the ice directly on your skin and don’t use an ice pack for more than 10 to 15 minutes at a time.

    Assess how you are sleeping. Are you grinding your teeth at night? If you are, it adds tension to your facial muscles. A sleep guard can be purchased at your local pharmacy that will help relax your lips and keep your teeth apart while you sleep.

    TMJ pain relief with physical therapy

    A physical therapist will be able to analyze your jaw mobility and release muscle tension in the neck and head area. Treatment for TMJ pain relief may include soft tissue mobilization, joint mobilization, myofascial techniques and jaw exercises. A physical therapist can also help address dietary changes that will bring your jaw joint relief.

    It’s time to stop suffering. Our physical therapists can help you manage and eliminate TMJ symptoms. Contact us today to schedule a one-on-one consultation and a complete, thorough evaluation.

  • Do you need manual therapy in Grand Rapids, MI?

    Do you need manual therapy in Grand Rapids, MI?

    Injury, age-related conditions and recovering from surgery can all cause pain and severely limit your normal range of motion. Along with other modes of treatment, physical therapy should be an essential part of your plan to find relief and regain mobility.

    One of the main tools in a physical therapist’s toolbox is manual therapy, which refers to several specific hands-on techniques. By manipulating the muscles, bones and joints in a specific area, a therapist can help that part of the body improve functioning.

    To determine if manual therapy can help you if you are a Grand Rapids, Michigan, patient seeking a return to an active lifestyle, Advent Physical Therapy is sharing the following information. We’re passionate about delivering top-tier care and want to help you make an informed treatment decision that’s right for you.  

    What types of conditions and injuries can manual therapy help with?

    Manual therapy uses methods like joint mobilization, soft tissue mobilization, targeted stretches and muscle contraction to increase range of motion and improve blood flow to the area, among other benefits. These methods can be effective for a very wide range of musculoskeletal injuries and conditions, including:

    • Neck pain, back pain and related symptoms
    • Shoulder pain, arm pain and wrist pain
    • Pelvic pain, hip pain and knee pain
    • Foot and ankle pain
    • Headaches
    • Post-surgical recovery
    • Arthritis
    • Fibromyalgia and chronic pain

    Physical therapy for these and other conditions can also include strength and stability exercises, dry needling, biofeedback and instruction on exercises and therapies that can be performed at home. When seeking a manual therapist, it’s important to find someone with the right skills and experience treating your condition. You also shouldn’t forget the importance of personal rapport in the treatment process — if you feel comfortable and at-ease with your provider, it can have a positive impact on your care.  

    The manual therapy experts at Advent Physical Therapy

    Since 1996, Advent has been helping west Michigan patients get their lives back with manual therapy and a full range of physical therapy offerings. With multiple clinics right in Grand Rapids, we’re here to help if you’re seeking manual therapy to relieve pain and improve mobility.

    Learn more about how we can help by contacting us and scheduling your initial appointment.

  • Physical therapy — the missing piece of pain management

    Physical therapy — the missing piece of pain management

    When you think of pain management, medication is probably the first thing that comes to mind. The problem is that medication typically treats the symptoms of pain and doesn’t treat the underlying source. This is where physical therapy comes in as a critical, often fundamental, part of managing pain associated with a wide range of conditions and injuries.

    In addition to improving or restoring function and mobility, pain relief is one of the primary goals of physical therapy. A qualified physical therapist can help you create a personalized treatment plan that is built on evidence-based pain management methods.

    Excel Sports and Physical Therapy is a team who is passionate about delivering patient-centered care, starting with education. Please take a moment to read the following information and feel free to reach out if you have any questions or would like to learn more.  

    How does physical therapy relieve pain?

    Physical therapy can relieve pain using a combination of active and passive techniques. Active therapies are exercises and other methods that patients do themselves while passive therapies are performed on patients, with or without the assistance of equipment.

    While physical therapy can provide short-term relief, the main goal is long-term pain management. This can be accomplished the following ways:

    • If a pinched nerve is the source of pain, physical therapy can relieve pressure on the nerve through exercises designed to improve posture and reduce painful movements.
    • Physical therapy techniques help increase blood flow to injured areas, assisting the natural healing process.
    • Following your therapist’s advice for healthy lifestyle choices, including practicing good posture, getting regular exercise and eating a nutritious diet, that can reduce pain and inflammation.

    It is critical to choose a physical therapist with the right credentials and experience who can help you create a care plan for your individual needs.  

    Excel Sports and Physical Therapy has decades of experience in pain relief

    With roots in providing physical therapy services in the greater St. Louis region that go back to 1984, our mission at Excel is to help you find relief and return to the quality of life you deserve. Our veteran staff has decades of combined experience in a wide breadth of physical therapy methods.

    If you’re in pain and want to learn more about how physical therapy can help, please contact us today to schedule your initial appointment.

  • Three reasons to see a physical therapist when you’re in pain

    Three reasons to see a physical therapist when you’re in pain

    Pain affects everyone in different ways. Some people find it difficult to complete certain daily tasks like getting dressed or showering. Others may not even be able to get around at all. No matter the situation, anyone who has chronic pain or pain from an injury can benefit from professional health care treatment.

    Physical therapists are licensed health care providers who help many people reduce their pain. Whether you have a chronic condition or are suffering from a sudden injury, there is a physical therapy treatment that can help you.

    Three reasons you need to see a physical therapist if you’re in pain

    Physical therapists are skilled in a variety of treatments that can treat all kinds of conditions that cause pain. At Continuum Wellness, our team takes the time to evaluate your condition and develop a personalized treatment for you.

    There are many reasons you would want to see a physical therapist for treating pain. Here’s a look at three of them we think you will love:

    1. Physical therapists help reduce pain — This is first on the list because reducing pain is likely the primary reason you want treatment for your condition. The main method for reducing pain in many physical therapy treatments is with stretching and exercising.

      Strengthening the muscles and soft tissue around the painful area improves support for the area and removes some pressure off of it. Physical therapists also use other techniques for reducing pain, including manual therapy, electrical stimulation or dry needling.

    2. Physical therapists help prevent pain — Often, the treatments that physical therapists use to reduce pain also serve to prevent future pain of a similar sort. Some types of chronic pain are the result of weak and stiff muscles, so strengthening and stretching the muscles helps prevent this kind of pain from developing.

    3. Physical therapists help improve your quality of life — If you’re having trouble getting around or completing certain tasks, physical therapists can help. Many physical therapy treatments include guidance for better balance and safer mobility. Physical therapists can also show you how to correctly use assistive devices like crutches or a walker if necessary.

    Visit Continuum Wellness for pain treatment

    If you have chronic pain or have been injured, you should talk to a physical therapist about treatment. Physical therapy treatments can help you treat pain without relying on surgery or drugs. Contact our team today for more information about physical therapy or to schedule an initial appointment

  • How to ease lower back pain

    How to ease lower back pain

    Lower back pain is among the most common health concerns that Americans face. The spine is an incredibly complex structure with dozens of small bones, discs and nerves that work together to facilitate motion, and the lower portion of the spine (lumbar spine) is particularly susceptible to injuries and degenerative diseases. If you begin to notice lower back pain, don’t panic. There are several self-care measures you can try to help ease your pain and get you back on the move, including

    • Temporarily avoiding high-impact activities, such as playing contact sports, lifting heavy objects and running  
    • Alternatively placing an ice pack and heating pad on the affected area to help reduce inflammation, numb pain and increase circulation
    • Trying gentle stretching exercises, providing you feel comfortable, to help release tensed back and hamstring muscles

    It’s important to note that you should immediately cease any activity that causes your symptoms to worsen. It’s also important to promptly consult with a physician if your symptoms do not improve in two days or if your pain is severe.

    How physical therapy can ease lower back pain

    A viable treatment option for your lower back pain may be physical therapy. Recognized as an effective way to reduce back pain by the Centers for Disease Control and Prevention (CDC), physical therapy aims to increase mobility, reduce discomfort and provide long-term symptom management through therapeutic exercises and passive modalities. Here is a brief overview of these approaches:  

    • Therapeutic exercise is a key component of physical therapy. While exercising with low back pain may seem counterintuitive, physical therapists recommend exercises that are strategic, gentle and designed to strengthen and stretch the muscles that support the spine. Gaining core muscle strength can also improve overall spinal health and reduce the risk of further injury.
    • Passive modalities are non-surgical treatments that are used in physical therapy prior to or following exercise to help maximize results. When treating low back pain, physical therapists may use ultrasound therapy to increase blood flow with gentle heat produced by sound waves, or transcutaneous electrical nerve stimulation (TENS) to halt pain signals to the brain, among other conservative techniques.

    Our approach to lower back pain treatment

    Panther Physical Therapy helps patients with lower back pain related to disc injuries, sciatica, spinal stenosis, osteoarthritis and other problems overcome their symptoms and regain their quality of life. We treat patients like members of our family, taking the time to carefully listen to their needs, confirm the root of their pain and design physical therapy regimens that are tailored to their unique needs.

    Our team has helped many patients successfully overcome their lower back pain without the need for potent drugs or invasive surgery, and we look forward to helping you do the same.

    Contact Panther Physical Therapy today to learn more information about our approach to lower back pain treatment or to schedule an initial appointment.

  • Chronic headache treatment in Saint Peters, MO

    Chronic headache treatment in Saint Peters, MO

    When looking for the right chronic headache treatment in Saint Peters, Missouri, you should look for physical therapy. At Excel Sports & Physical Therapy, our team of knowledgeable and professional staff members work with you to evaluate your condition, listen to your concerns, answer your questions and get you feeling better as soon as we can.

    Whether you suffer from migraines, tension, cluster, sinus or temporal headaches, none of those are better than the other, and all of them can make an every day miserable. You’ve probably tried numerous medications, looked up alternative treatments and just haven’t had any luck. When you tackle these chronic headaches head on with one of our physical therapists, the causes of them will be determined and a treatment plan will be created.

    When it comes to physical therapy as headache treatment, we look at what your body is telling us. We will check for the following:

    • Misalignment in the neck
    • Posture issues
    • Strength of the neck muscles
    • Issues in the upper back and shoulders
    • Joint mobility in the neck

    All of the above factors and more can be the reason you are in need of chronic headache treatment in Saint Peters. Physical therapy can be the key to healing your pain and making it as infrequent as possible. Our therapists will work with you to restore the correct movement and alignment of your muscles and joints through a series of treatment plans in order to relieve you of the chronic headaches as much as possible. This will also help with increased blood flow and will come along with exercises you can do at home in the event of a flare-up.

    Don’t wait to look for chronic headache treatment in Saint Peters. The faster you get help, the more days you’ll have that are much less painful and hopefully pain-free altogether.

    Contact Excel Sports & Physical Therapy today with any questions and schedule your initial appointment.

  • How to relieve a sore neck

    How to relieve a sore neck

    If pain and stiffness has left you searching for sore neck treatment, you’re in good company. Neck soreness is among the most common orthopedic issues that people face. The neck (cervical spine) features a complex structure of small bones, nerves and muscles that work together to facilitate movement and support the weight of the head, which weighs about as much as a bowling ball! Actions as seemingly minor as sleeping in an awkward position or staring at a computer screen for too long can lead to the need for sore neck treatment, as can common musculoskeletal issues like muscle strains, whiplash, osteoarthritis and bulging discs.

    What does sore neck treatment involve?

    Each patient’s ideal course of treatment will vary according to his or her overall health and the underlying cause of symptoms. Some patients can find adequate symptom relief through simple self-care measures, including:

    • Periodic rest
    • Hot/cold therapy with heating pads and ice packs
    • Gentle stretching
    • Over-the-counter pain medications

    If your neck pain persists or worsens despite a few days of trying self-care measures, or if it is accompanied by numbness or tingling sensations, it’s time to consult with a medical professional. Many neck pain treatment plans include physical therapy to strengthen and stretch the muscles that support the neck and help correct alignment issues.

    Our approach to sore neck treatment

    Panther Physical Therapy provides comprehensive sore neck treatment from compassionate and experienced physical therapists. We utilize therapeutic exercises, manual therapy techniques and other evidence-based methods to encourage proper neck alignment and promote overall musculoskeletal health. Through our conservative approach, we are able to help patients of various ages overcome their symptoms without potent medications or invasive surgery.

    Don’t allow your symptoms to become a pain in the neck. Turn to Panther Physical Therapy for the expert sore neck treatment you need and deserve. Contact us today to schedule an initial appointment.

  • A trusted provider of chronic pain treatment in Harmony, PA

    A trusted provider of chronic pain treatment in Harmony, PA

    If chronic pain has left you searching for treatment, Panther Physical Therapy is here to help. Our physical therapy center in Harmony, Pennsylvania, provides hope to patients who require treatment for chronic pain from a variety of neurological and musculoskeletal sources, and has proudly done so since our founding in 2003.

    What does chronic pain treatment entail?

    “Chronic pain” is defined as pain that lingers for more than 12 weeks. Unlike acute pain that typically points to a specific injury, the source of chronic pain is sometimes much less clear. Because of this, the first step of treatment is often finding its source. Several techniques may be used to diagnose chronic pain, such as neurological and physical examination, blood work and various imaging tests. Patients may also be asked about how their feelings factor into their symptoms, as many types of pain have an emotional response.

    The specifics of pain treatment will vary from patient to patient. Based on each individual’s diagnosis and symptoms, the physical therapists at our center in Harmony, Pennsylvania, may suggest evidence-based techniques like therapeutic exercise and manual adjustments, and conservative methods like ultrasound therapy and transcutaneous electrical nerve stimulation (TENS), to reduce or eliminate pain and maximize mobility. This approach helps our patients avoid potentially addictive narcotics and other medications that are temporary fixes.

    Do I need chronic pain treatment?

    Many people tend to give up on finding relief from their chronic pain and simply accept their symptoms as a normal part of life. At Panther Physical Therapy, we believe this should never be the case. Even if a patient’s chronic pain cannot be completely cured, there are several steps that can be taken to effectively manage symptoms and enjoy a better quality of life.  

    We encourage you to contact our center in Harmony, Pennsylvania to learn more or to schedule an initial appointment. We would be happy to provide you with more information about our practice, therapists and conservative approach to chronic pain treatment.

  • Five tips for getting the best results in occupational rehab

    Five tips for getting the best results in occupational rehab

    If you’ve never injured yourself at work, then you may have no idea what occupational rehab is. However, it’s vital you know a little about it in case you do injure yourself at work. At Excel Sports & Physical Therapy, we can help you find great occupational rehab. We can also give you five tips for getting the best results in occupational rehab.

    Our Excel Sports & Physical Therapy team has 35 years of experience providing high-quality physical therapy for the residents of the greater St. Louis area. During all these years in business, we’ve learned some valuable lessons about what makes great physical therapy. One lesson we’ve learned is that personalized therapy tends to be far more effective. This is why we’ll always build you a treatment plan that uses specific therapies designed to treat your injury or medical condition. Our experience also allows us to provide you with five tips for getting the best results in your occupational rehab.

    The five tips you can use to get the best results from occupational rehab


    There are five tips you can use to get the best results from occupational rehab. However, before we discuss these tips, you should understand what occupational rehab is and what it’s used for.

    Occupational rehab uses methods designed to help people regain their ability to do work-related tasks. This goal is different from the goal of physical therapy. The goal of physical therapy is to help build or rebuild muscle strength, balance and other physical aspects of your body.

    There are many work-related injuries and medical conditions that occupational rehab can treat. For instance, this form of therapy can be used to treat injuries like carpal tunnel syndrome that result from repetitive movements. Occupational rehab is also helpful for treating people who have developed sciatica from sitting too much at work. This type of rehab program can be designed to help you treat injuries that result from other factors. Some of these factors include lifting heavy objects, being struck by falling objects or work-related motor vehicle accidents.

    Occupational rehab programs from Excel Sports & Physical Therapy are always designed to provide great results. But, there are five tips you can use that may help you achieve the best results in your occupational rehab, including:

    1. Maintaining a positive attitude
    2. Diligently performing both in-office and at-home therapy exercises
    3. Asking questions about your condition or therapy
    4. Making sure you get enough sleep
    5. Listening to the advice of your therapist

    Are you looking to get the best results out of your occupational rehab after a workplace injury? Our team at Excel Sports & Physical Therapy can help you do just that.

    Contact our team today for more information or to schedule an initial appointment.

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