Intrinsic Physical Therapy

Chronic Illness General Persistent Pain

Cranial Cervical Instability (CCI)

Do you feel like a bobble head somedays? Feeling like your head is unstable on top of your neck can be a common symptom of joint hypermobility.

The full name and diagnosis for joint hypermobility at the junction where the neck meets the head is Cranial Cervical Instability or CCI. This can come as a diagnosis on its own, but often accompanies an EDS diagnosis. CCI can also result from trauma, Chiari malformation, tethered cord syndrome or other conditions such as RA or Down’s Syndrome. 

The two main joints affected are the atlanto-occipital joint (where the first cervical vertebrae meets the skull) and the atlanto-axial joint (between the first and second vertebrae). As with other joints in our body, the joints in our upper neck are surrounded by ligaments to provide support. Our neck has to work hard to stabilize a heavy head, and if you have connective tissue issues where the ligaments are more lax, you may feel like it is difficult to hold your head up.

Because of the anatomy at the cranio-cervical junction, symptoms of CCI can be vast and much more than “neck pain”. CCI can result in compression at the brainstem, which can contribute to blood flow issues and cranial nerve compression, which accounts for the wide range of symptoms. Cranial nerve X, also known as the vagus nerve, is often affected with CCI. The vagus nerve controls parasympathetic activity in the heart, lungs and digestive tract and may be one cause of POTS. This can explain why we often see EDS and POTS together, as well as why we might see POTS develop after a head injury or concussion. 

Symptoms of CCI include:

  • Headaches/Migraines
  • Neck, jaw or shoulder pain
  • Dizziness, lightheadedness or syncope
  • Balance issues
  • Visual disturbances: light sensitivity or blurred vision
  • Brain fog
  • Rapid heart rate
  • Ringing in the ears
  • Nausea or vomiting 
  • Dysautonomia
  • Shortness of breath
  • Difficulty swallowing
  • Muscle weakness
  • Numbness or tingling in the extremities

So how is CCI diagnosed?

Working with a physical therapist who is familiar with the condition is a good place to start if you are wondering about CCI because they will be able to assess for ligamentous laxity at the upper cervical segments. They will perform a manual assessment, combined with a thorough subjective history and evaluation of signs/symptoms throughout the body and this will often provide enough information to understand the etiology and create an appropriate treatment plan.

A formal diagnosis of CCI will require imaging. Typically, an upright MRI with flexion/extension is utilized, with doctors looking for 3 specific measurements: the Clivo-Axial angle, the Grabb-Oakes measurement and the Harris measurement. A CT scan can also look for CCI.

What does treatment entail?

Treatment for CCI will be dependent on the severity of symptoms and can involve physical therapy, bracing, injections or surgery.

Physical therapy can provide a conservative, holistic approach, which is often required for long-term benefit. A physical therapist can provide a wide variety of treatment strategies such as manual therapy, postural alignment, strengthening and stability, proprioception, ocular-motor and vestibular exercises. A PT can also guide a person in the use of cervical bracing, if appropriate, as well as pacing, functional movement strategies and pain neuroscience education.

PRP injections have been utilized more recently as they gain popularity and some people have found great benefit from these injections.

Surgery, which typically involves an upper cervical fusion, is used as a last resort or when neurological changes are severe. 

It is possible to live a high functioning life with CCI and working with a provider who has an understanding of this condition can help immensely! 

Do you have more questions about cervical instability? Schedule a free discovery call and let’s chat! 

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