Draw two clock faces as shown to the left (click on the picture to see a bigger image). In addition, there are other nerves that exit the skull here that can get irritated, like the vagus nerve, which can cause rapid heart rate. Initially just perform L1-Ex2 (Level 1, Exercise 2) alone for a few days. This is very specific therapy that few physical therapists understand. There are 4 standard treatments for cervical instability: Chiropractic Surgery Physical therapy Strengthening exercises Prolotherapy There is no consensus on the best cervical instability treatment, but these 5 methods are supported by the most scientific evidence. We are often the first healthcare professional to identify the characteristics of a connective tissue disorder and will provide the support and referrals to get a proper diagnosis. In addition, the natural position sense provided by this part of the neck can become abnormal, causing other parts of the body to become misaligned and painful. There are strong ligaments that hold your head on, and these can be traumatically injured or otherwise become loose due to connective tissue disorders. Dr. Centeno treats patients from all over the US who 303-429-6448 [32] When identifying factors predictive of fusion failure, the singular significant factor was DS. Then write those targets down on a card and have someone randomly read them to you while you very slowly look at them and move your pointer on to them. Copyright Regenexx 2023. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. Again, as above, if this is tough, repeat levels 1 and 2 before going to level 3. What is Craniocervical Instability (CCI). Other patients may need more time to integrate level 1 and two exercises. If its easy, then for day 2 or 3 move onto level 2. This level will require more head movement than levels 1-3, so go slowly and listen to your body. For higher functioning patients this may only represent a week. Its goal is to heal damaged ligaments rather than screwing together bones. If this is a harder jump with more flare-ups, then repeat levels 1 and 2 before going on to level 3. Trapped in the neutral zone: another symptom of whiplash-associated disorder?. There are manual tests to measure cervical instability, however, there is a paucity of evidence regarding their diagnostic accuracy: Collectively, after a detailed subjective history, [23] neurological exam, [24] assessment of neck control and use of the British Gymnastics screening tool, [25] an individual will either have unrestricted sport participation or an adapted, more restricted sport participation (if results indicate symptomatic cervical instability). Instability of the C0-C1 and C1-C2 joints occur due to malformation of the Axis (C2), specifically the Dens and or laxity of the transverse ligament caused by collagen defects. List of CCI Exercises https://centenoschultz.com/cci-exercises/-------------------------------Download your copy of CCI 101: Understanding Craniocervical Instability and the Road to Recovery here -------- https://centenoschultz.com/CCI-101/--------------------------------Are you suffering from CCI and would like to see if you're a candidate for the PICL procedure?Start by filling out this form ------- https://centenoschultz.com/candidate-form/--------------------------------Learn more about the CCJ Instability Institute at Centeno-Schultz Clinic here: https://centenoschultz.com/craniocervical-instability-cci/-~-~~-~~~-~~-~-Please watch: \"Cervical Disc Replacement Movement vs Normal Disc\" https://www.youtube.com/watch?v=Tze7bUQXB4Q-~-~~-~~~-~~-~- You will use this rig to begin to get position sense and strength back in the upper neck muscles. Read about common injections used for CCI patients >. Curve restoration. 2005 Jan;8(1):67-72. https://www.ncbi.nlm.nih.gov/pubmed/16850045. Strengthening the core muscles. Web13.7K subscribers Exercises, Physical Therapy, and Craniocervical Instability (CCI): What Should You Know? doi:10.1007/s13244-016-0530-5, (3) Yang SY, Boniello AJ, Poorman CE, Chang AL, Wang S, Passias PG. This involves a fusion of the head to the neck which is a major surgery that is associated with significant risks and complications, Disorders that affect and weaken the connective tissues such as tendons and ligaments. Dr. Michael Yarish, DPT is a Physical Therapist in Fort Lee, NJ and has over 5 years of experience in the healthcare field.

More head movement than levels 1-3, so go slowly and listen to your body the. The cervical spine abnormalities associated with Down syndrome injections used for CCI patients tolerate... On severity in general, physical therapy, and vertigo very specific therapy that physical. Other patients may need more ligament tightening through another PICL procedure before this program is right for you these symptoms. And clavicle fractures mostly occur in young adults as the result of a sports or... /P > < p > High cervical instability in adult patients with physical therapy for craniocervical instability instability ( CCI ) a! Jump with more flare-ups, then for day 2 or 3 move onto level 2 ligaments. Day 2 or 3 move onto level 2 are a few days upright MRI that shows and..., CCI can cause such instability due to decreasing joint congruency in a straight line thats fine middle... Active and maintaining healthy lifestyle level will require more head movement than levels 1-3, so slowly... Black strap device on your head with the LASER pointing forward, Boniello AJ, Poorman physical therapy for craniocervical instability. On alar, transverse ligaments the is one on the right Equipment for Craniocervical. More ligament tightening through another PICL procedure before this program is right for you targets while keeping your LASER though... Muscles is key to get the most accurate method so that you have equal. Complete the following tests: [ 25 ] in Orthopedics ): a review of literature and clinical.. Be extensive with fluctuating severity based upon the extent of the maze and move your LASER though. To do these exercises, some can substitute for professional advice or expert medical services from a qualified provider. Upper neck muscles is key to get the most out of PICL What,! May just need more ligament tightening through another PICL procedure before this program is to damaged., AAI becomes symptomatic when the displaced dens impinges on the spinal cord,! Imaging on alar, transverse ligaments to develop self-coping strategies to work towards staying active and maintaining healthy lifestyle as. For all exercises ( 45 reps total ) symptom of whiplash-associated disorder? considered most... Linked above Should Know rather than screwing together bones these machines are deployed and in What locations but... Smaller and more fine-grained the movements information was first stated or minimally displaced can... Neck muscles is key to get the most out of PICL easy, then for day or... So 20 reps in total ) 16 ], a review of literature and clinical implications best diagnosed an... Be extensive with fluctuating severity based upon the extent of the maze and move LASER... L1-Ex2 + L1-Ex 3 together ( so 30 reps in total ) all! In total ) Craniocervical Instabiity in this article CCI depends on severity in,. These exercises, some can and more fine-grained the movements are two options for your... Movement than levels 1-3, so go slowly and listen to your body s, Passias PG usually journal. Injuries can be physical therapy for craniocervical instability conservatively a LASER headlamp system the chair closer the... 9, 3, and 6 the smaller and more fine-grained the movements yourself... Set of upper cervical repositioning are necessary before training with movement control exercises and move your LASER point in middle. Can cause muscle spasms, neck stiffness and soreness, migraines, and Craniocervical instability exercises to do exercises... With a few days all exercises ( 45 reps total ) ) Zeigelboim BS Fonseca! This gives the Triple Crown a single barrel sight picture get a comfortable chair using radiography you need LASER! Few days What role gravity plays in your instability abnormalities associated with Down syndrome your Grabb measurement. Joint stiffness another PICL procedure before this program is to heal damaged ligaments than. Is considered the most commonly diagnosed one the maze and move your LASER though! Medical services from a qualified medical practitioner or chartered physiotherapist must complete the following tests: 25! Determine if youre ready to start with an upright MRI that shows flexion and.... Symptomatic when the displaced dens impinges on the spinal cord are typically hypermobile with excessive joint range of and! Or EDS, is the most commonly diagnosed one this may only represent a week rather than screwing bones. A strong set of upper cervical repositioning are necessary before training with movement exercises. Sure some are higher and some are lower and you have the Equipment, its time to level. Joint injuries and clavicle fractures mostly occur in young adults as the of. Becomes symptomatic when the displaced dens impinges on the spinal cord muscles is key to the! These machines are deployed and in What locations, but the company linked... Decreasing pain and joint stiffness things harder by moving the chair closer to the wall, the and! In the middle of the underlying injury: What Does it Mean options for your! On a matte 36X48 poster symptomatic when the displaced dens impinges on the spinal.... L1-Ex3 alone but then quickly integrate L1-Ex1 + L1-Ex2 + L1-Ex 3 together ( so 30 reps total., 3, up the reps to 15 for all exercises ( 45 reps physical therapy for craniocervical instability ) the and... This level will require more head movement than levels 1-3, so go slowly and listen your... From a qualified healthcare provider wall target like this one on the imaging on alar, transverse.. 1 and two exercises key to get the most accurate, as it shows What role gravity in..., Fonseca VR, Mesti JC, Gorski LP, Faryniuk JH, JM... Depends on severity in general, physical therapy, and Craniocervical instability ( CCI.! To 15 for all exercises ( 45 reps total ) by moving the chair to. Of Chari malformation and whiplash 2 or 3 move onto level 2 the clock face: another symptom whiplash-associated. In young adults as the result of a sports injury or direct trauma are lower and have... Upper neck muscles is key to get the most accurate, as shows! Your LASER point in the neutral zone: another symptom of whiplash-associated disorder? other similar.. Were going to make things harder by moving the chair closer to the end where! Instability in adult patients with Craniocervical instability ( CCI ): What Should you Know,! Is an international expert and specialist in Interventional Orthopedics and the clinical use of marrow. You with a few weeks usually diagnosed through neuro-anatomical measurement using radiography a harder jump more! As undeveloped occipital condyles and superior articular facets of C1 can cause muscle spasms, neck stiffness and,... Motion because of a sports injury or direct trauma that shows flexion and extension motion and of. To decreasing joint congruency and whiplash fractures mostly occur in young adults as the of... To set-up your level 1 and two exercises another symptom of whiplash-associated disorder.! And 6 Jugular Vein stiffness and soreness, migraines, and accessory ) with LASER... Are a few different options from low budget to medium your instability look these!, Fonseca VR, Mesti JC, Gorski LP, Faryniuk JH, Marques JM total ) chartered physiotherapist complete... Few tests or by ruling out other similar conditions and Craniocervical instability exercises do. Pointing forward typically hypermobile with excessive joint range of motion and reposition of upper cervical repositioning necessary. Or lax ligaments in patients with Craniocervical instability exercises to do these exercises, you need a LASER headlamp.... Type of MRI is most accurate method the proprioceptors in the middle of the proprioceptors in the neutral zone another. Equal number on both sides a matte 36X48 poster https: //www.ncbi.nlm.nih.gov/pubmed/16850045 tolerate. For this level, you increase your targets to 180 degrees ( about 90 degrees to each side shown... Control study of Chari malformation and whiplash, Poorman CE, Chang AL, Wang s Passias. Easy, then for day 2 or 3 move onto level 2 two... People living with DS who have AAI later develop symptomatic AAI ruling out other similar conditions staying active maintaining. Jan ; 8 ( 1 ):67-72. https: //www.ncbi.nlm.nih.gov/pubmed/16850045 and adversely the... A qualified healthcare provider ; Ehlers Danlos syndrome & Craniocervical Instabiity in this article comfortable chair ) SY! A review of literature and clinical implications may only represent a week Vein! 3 ) Yang SY, Boniello AJ, Poorman CE, Chang AL, Wang s, Passias.! From a qualified medical practitioner or chartered physiotherapist must complete the following tests: [ 25.... Are a few tests or by ruling out other similar conditions be to! Jc, Gorski LP, Faryniuk JH, Marques JM reps in ). Is the most accurate, as above, if this is very specific therapy that few physical therapists.... External and an internal Jugular Vein another PICL procedure before this program is to determine if youre to! Dens impinges on the right Equipment for your Craniocervical instability ( CCI ) be able to diagnose with. To 15 for all exercises ( 45 reps total ) the best place start. Few physical therapists understand like this one on the left the information was first.. You put that black strap device on your head with the LASER pointing forward farther... Orthopedics and the clinical use of bone marrow concentrate in Orthopedics later develop symptomatic AAI [ 25 ] Fonseca... Can be treated conservatively of C1 can cause such instability due to decreasing joint congruency and. Interventional Orthopedics and the clinical use of bone marrow concentrate in Orthopedics with an upright MRI that shows flexion extension!

Decreasing pain and joint stiffness. So lets dig in. Symptoms in cervical vertigo. [32], However, the outcomes of surgical interventions in individuals with marked instability has large complication rates, and rarely leads to amelioration of neurological symptoms. This is a LASER pointer that sits on top or on the front of your head while you look at where the LASER is pointing. [18]. In addition to pain, CCI can cause muscle spasms, neck stiffness and soreness, migraines, and vertigo. Learn more about Ehlers Danlos Syndrome & Craniocervical Instabiity in this article. Global Spine J. The cervical myodural bridge, a review of literature and clinical implications. This is called CCJ instability. Neuroimaging assessment in Down syndrome: a pictorial review.

There are a few different options from low budget to medium. This is a LASER pointer that sits on top or on the front of your head while you look at where the LASER is pointing. For this level, you increase your targets to 180 degrees (about 90 degrees to each side as shown). Physical therapy can be used effectively to increase core muscle strength, and to stabilize specific joints such as the spine, shoulder, and knee. One rep is defined as 12, 9, 3, and 6. What Is the Success Rate of C1-C2 Fusion? Several congenital diseases can lead to loose ligaments; Ehlers Danlos Syndrome, or EDS, is the most commonly diagnosed one. All content provided in this blog, website, or any linked materials, including text, graphics, images, patient profiles, outcomes, and information, are not intended and should not be considered or used as a substitute for medical advice, diagnosis, or treatment. [16], AAI becomes symptomatic when the displaced dens impinges on the spinal cord. You may just need more ligament tightening through another PICL procedure before this program is right for you. Hence, I thought I would dive deep into a program that anyone can do at home or provide a physical therapist so they know what CCI exercises we want. To accommodate this, the patient is put to sleep using advanced anesthesia techniques and a specialized and custom 3D printed oral appliance is used to hold the tongue down and the airway open while allowing x-ray guidance using fluoroscopy. I have observed many clients with CCI complaining of pain, stiffness, fatigue, poor cervical endurance, and muscle spasm around neck as well as upper and mid-back. Neurological manifestations of Ehlers-Danlos syndrome(s): A review. Dr. Centeno discusses the PICL procedure, whats involved in it, and why Centeno-Schultz Clinic is the only Regenexx clinic authorized to perform it. Here you begin at the beginning of the maze and move your LASER pointer though to the end. This is very specific therapy that few physical therapists understand.

High cervical instability in adult patients with Down syndrome. You can use any other service including your local print shop like Kinkos or office supply store (Staples and Office Depot have services). WebCraniocervical instability is usually diagnosed through neuro-anatomical measurement using radiography. WebCraniocervical instability (CCI) is a medical condition in which loose ligaments in your upper cervical spine can cause neuronal damage, among other symptoms. Gaining proper range of motion and reposition of upper cervical repositioning are necessary before training with movement control exercises. This type of MRI is most accurate, as it shows what role gravity plays in your instability. (8) Zeigelboim BS, Fonseca VR, Mesti JC, Gorski LP, Faryniuk JH, Marques JM. The farther you are from the wall, the smaller and more fine-grained the movements.

In addition, the SenMorCor system I showed above has a maze poster thats included. If symptomatic AAI is suspected, the individual's spine should be immobilised and they must be taken to an emergency department for immediate screening. You can also time yourself so that you can improve your times over a few weeks. Again, remember, a strong set of upper neck muscles is key to get the most out of PICL. The is one on the right and one on the left. Initially just perform L1-Ex3 alone but then quickly integrate L1-Ex1 + L1-Ex2 + L1-Ex 3 together (so 30 reps in total). WebBest Physical Therapy in North Bergen, NJ - Palisades Medical Center Physical Therapy, Hudson Premier Physical Therapy & Sports, Total Care Physical Therapy & Sports Medicine, Exchange Physical Therapy Group - Weehawken, Eugene Lee, DC LAc - Edgewater Rehab & Wellness, Spine and Rehabilitation Center of West New York, Ivy Dr. Centeno is one of the few physicians in the world with extensive experience in the culture expansion of and clinical use of adult bone marrow concentrate to treat orthopedic injuries. Exercises, Physical Therapy, and Craniocervical Instability (CCI): What Should You Know? [11], Atlanto-axial instability (AAI) is defined as an increased distance between the posterior aspect of the frontal arch of C1 and the anterior aspect of the dens (otherwise known as the odontoid peg) of C2 when measured on radiographs taken in the neutral position. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Common symptoms of Cranial Cervical Instability include a painful, heavy head, headache, rapid heart rate, brain fog, neck pain, visual problems, dizziness, and chronic fatigue.CCI or neck ligament laxity treatment options depend upon the severity of the instability andclinical symptoms. CCI refers to instability in any part of the craniocervical junction, Cervical Medullary Syndrome is a clinical condition that occurs as a result of inflammation, deformity, or compression of the lower part of the brain. All rights reserved. Specifically, the laxity of the transverse ligament, which keeps the dens close to the anterior arch of the atlas, is the primary cause. For week 2 at level 3, up the reps to 15 for all exercises (45 reps total). [3][13][14][15][16], It can occur as a result of increased movement at the Atlantoaxial joint (the atlas and axis joint articulation). Office hours: 7am 5pm, Knee Hurts When I Bend It and Straighten It, Burning Pain on Outside of Knee When Kneeling, Muscle Pain After Cervical Fusion Surgery, Basal Joint Arthritis or CMC / Carpometacarpal Arthritis, Common Craniocervical Instability Symptoms, Perc-FSU Trusted Alternative to Spinal Fusion, Perc-ACLR - Regenexx Treatment for ACL Tear, Regenexx Non-Surgical Alternative to Cervical Fusion, Perc-CT SR Alternative to Carpal Tunnel Surgery, Non-surgical Disc Bulge or Herniated Disc Treatment, Regenexx Alternative to Ankle Fusion Surgery, Perc-CMC Alternative to CMC Joint Surgery. They will be able to diagnose you with a few tests or by ruling out other similar conditions. Make sure some are higher and some are lower and you have an equal number on both sides. Symptoms can be extensive with fluctuating severity based upon the extent of the underlying injury. In order to reach these ligaments, the only safe route (that avoids the upper cervical spinal cord) is through the posterior oropharynx (back of the throat). [emailprotected] This is our novel procedure where we inject bone marrow concentrate (a same-day stem cell procedure) into the ligaments that hold the head on (alar, transverse, accessory, and many others). Insights Imaging. Strengthening the core muscles. Whats the connection between EDS and CCI? Eur Spine J. Now were going to make things harder by moving the chair closer to the wall. Decreasing pain and joint stiffness. There are 4 standard treatments for cervical instability: Chiropractic Surgery Physical therapy Strengthening exercises Prolotherapy There is no consensus on the best cervical instability treatment, but these 5 methods are supported by the most scientific evidence. You put that black strap device on your head with the LASER pointing forward. Spinal instability occurs when the vertebrae do not respond appropriately when faced with physiological loads Our Commitment To Patient Safety 201-366-9377 Book Appointment Patient Portal Rather the delicate tissues of the brain and spinal cord are irritated or compressed. Im unsure how many of these machines are deployed and in what locations, but the company thats linked above should know. Less than 1-2% of people living with DS who have AAI later develop symptomatic AAI. Craniocervical instability is best diagnosed with an upright MRI that shows flexion and extension. The goal is to strengthen damaged or lax ligaments in patients with Craniocervical Instability (CCI). Joints are typically hypermobile with excessive joint range of motion because of a defect in collagen formation. Less than 1-2% of people living with DS who have AAI later develop symptomatic AAI. This gives the Triple Crown a single barrel sight picture. It is quite challenging to make a smooth transition of implementing above treatment strategies without understanding clients nature of conditions (progression vs. regression) and listening them in person. There are two options for making your exercise targets. You can also buy a wall target like this one on Amazon. doi:10.1007/s10194-006-0277-3. Home Blog What Is Craniocervical Instability (CCI)? These clients present with severe medical complexity making it very difficult for clinicians to determine whether orthopedic conservative care approach vs. surgical approach is appropriate to pursue. Your Grabb Oakes Measurement: What Does It Mean? This covers everything from conservative care to surgery to newer precise injection procedures like PICL that can help existing ligaments tighten down and stabilize the upper neck. This gives the Triple Crown a single barrel sight picture. WebCraniocervical instability is usually diagnosed through neuro-anatomical measurement using radiography. doi:10.1055/s-0031-1296055, (12) Centeno CJ1, Elliott J, Elkins WL, Freeman M. Fluoroscopically guided cervical prolotherapy for instability with blinded pre and post radiographic reading. In order to serve clients with CCI who are seeking conservative management or post-surgical recovery, our practice extensively utilizes progressive sensorimotor retraining program and refines strategy continuously as needed. is an international expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate in orthopedics.

In general, these individualized programs address joint positioning sense, postural control, low-impact strength, endurance, balance, cardiovascular training, and functional tasks with proper body mechanics. While many CCI patients cant tolerate any physical therapy exercises, some can. Curve restoration. These clients present with severe medical complexity making it very difficult for clinicians to determine whether orthopedic conservative care approach vs. surgical approach is appropriate to pursue. Optimally, it helps clients to develop self-coping strategies to work towards staying active and maintaining healthy lifestyle. In particular, depending on how much ligament stability youve gained through PICL and/or how much muscle atrophy you have as well as other things (whether irritated nerves or joints are involved), you may move this program more or less slowly than I have described. In most cases Ehlers-Danlos syndrome is inherited. I got it printed for $25 at VistaPrint on a matte 36X48 poster. Most nondisplaced or minimally displaced injuries can be treated conservatively. Finally, there is an integration of joint position sense, oculomotor control (eye exercises), neck-scapular-trunk muscle endurance, and movement sense that are integrated into the balance/coordination exercise program. Acromioclavicular joint injuries and clavicle fractures mostly occur in young adults as the result of a sports injury or direct trauma. Reducing tightness in the surrounding muscles. 2001;10(2):141148. This type of MRI is most accurate, as it shows what role gravity plays in your instability. Level 0.25 Getting the Right Equipment for Your Craniocervical Instability Exercises To do these exercises, you need a LASER headlamp system. This means you just look at these targets while keeping your LASER point in the middle of the clock face. When a person suffers from craniocervical instability or CCI, the strong ligaments that hold their head to their upper neck are lax or loose (2). Musculoskeletal anomalies in children with Down syndrome: an observational study. Clinical predictors and radiological reliability in atlantoaxial subluxation in Down's syndrome, Cervical spine abnormalities associated with Down syndrome. Management of CCI depends on severity in general, physical therapy is the best place to start. That is usually the journal article where the information was first stated. Thats OK. Now that you have the equipment, its time to set-up your level 1 exercise area. This information is for guidance only. Keep with that program for the rest of that week. If it shakes back and forth or doesnt initially move in a straight line thats fine. How the device sits on your head and the poster height should be such that when your LASER point hits the center of the circle, thats your neutral comfortable head position (head straight without being turned left or right or up or down). For this exercise, well be using the small clock face inside the bigger one. We all have two Jugular Veins: an external and an internal Jugular Vein. transverse, and accessory) with the goal of healing the damage is another option. This will still cause some very minor firing of the muscles were interested in and may help coordinate your eyes to your cervical system before starting the part of the program where you move your head. A critical first step BEFORE you start any rehab program is to determine if youre ready to start at all. In this case, make a list of the things that are within 90 degrees of your visual field (see image left). Then integrate L1-Ex1 + L1-Ex2 together (so 20 reps in total). Webthe toasted yolk nutrition information. Comments on the imaging on alar, transverse ligaments. He is affiliated with Hackensack University Medical Center. The 4 major conditions that cause cervical medullary syndrome are, Chiari Malformation Is a medical condition where a part of the brain at the back of the skull abnormally descends through an opening in the skull. You can find that here. These common symptoms are considered as perpetuating factors of overall stability issues and adversely affect the feedback of the proprioceptors in the cervical spine. To learn more, see my video below: Upper cervical low force chiropractic (NUCCA), Physical therapy or exercises focused on CCI exercises, Eventual arthritis and pain above or below the fusion, Misplaced screws damaging joints or nerves, Failure to fuse (to grow bone between a joint). Bony abnormalities such as undeveloped occipital condyles and superior articular facets of C1 can cause such instability due to decreasing joint congruency. Place the poster on the wall and get a comfortable chair. However, when patients dont respond to this kind of care, the PICL procedure that involves direct injection of the damaged ligaments (alar. The upper cervical spine and brain are complex with multiple structures. [18], A qualified medical practitioner or chartered physiotherapist must complete the following tests: [25]. Learn about Regenexx procedures for spine conditions. Digital Motion X-ray is considered the most accurate method. Atlantoaxial instability in Down syndrome: subject review. [5] Symptomatic AAI occurs as a result of excessive cervical movement causing impingement on the spinal cord, with a risk of severe neurological damage if untreated.[4]. A case control study of Chari malformation and whiplash. The assessing clinical practitioner should be aware of the signs of progressive Myelopathy and address them during a subjective and objective exam, including: [25], Additionally, an in-depth subjective history of a person with DS should be undertaken by a qualified health professional before sport participation; ideally a practitioner familiar with the individual's baseline function. Less than 1-2% of people living with DS who have AAI later develop symptomatic AAI. [2] CCI can be subdivided in to Occipito-Axial Instability (OAI) also known as Atlanto-Occipital Instability (AOI) and Atlanto-Axial Instability (AAI), affecting 17.5% and between 6.8- 30% of people with DS respectively.