Conservative Treatment for Atlantoaxial Instability


Reference Finland 1998

“Twenty patients with rheumatoid atlantoaxial subluxation (AAS) underwent an active conservative treatment programme, aiming at relieving the symptoms and influencing the natural course of AAS/AAI…. Cervical pain was significantly reduced (P<0.001) during the first intervention, and the favourable effect continued at least 12 months. Promising changes were also seen in some cervical radiographs. It is possible to educate and motivate AAS/AAI patients to take active care of their neck, and to relieve their chronic neck pain significantly. Atlantoaxial instability may also be reduced during active conservative treatment…. In three cases, the instability had been reduced by 3 mm during the follow-up.

The treatment consists of elements:  patient education, physiotherapy, collars, practical aids, symptomatic treatments and active disease-modifying medication.

Patient Education: Cervical spine anatomy and a main point is that the flexion position is harmful in cases with unstable AAS/AAI and patients should avoid it.   Ergonomics was also taught.

We conclude that it is possible to educate and motivate AAS/AAI patients to take active care of their neck, relieve their chronic cervical pain and probably influence the natural course of the rheumatoid cervical spine…to prevent complications and to reduce the need for operative treatment.”


Physiotherapy was given individually and each patient received individual instructions for home exercises.  Cervical pains in AAI cases are mostly of muscular origin and thus the treatment is aimed at reducing muscular tension and inducing their fitness.

We suppose that the six small muscles of the occipital triangle are especially important in AAS/AAI.  They interconnect the occipital bone, atlas and axis, and extend and rotate the head, but are also postural muscles responsible for fine movements of the head and the cooperate with the eye muscles.  Much effort was aimed at the strength and endurance of these and their antagonists, the deep flexors.  Isometric or only slightly dynamic exercises (flexion, extension, rotation) against compliant resistance such as a finger…. exercises of the larger neck and shoulder muscles were also performed, but dynamic flexion and maximal rotation were avoided.

One aim was the maintenance of good posture, and exercises were performed to improve the posture of the entire body, as well as of the neck.  Muscle relaxation methods were also taught to the patients. ”

Note:  Here is a video of Upper CERVICAL SPINE STABILIZATION: Best Exercises for CRANIOCERVICAL Instability | C0-C1 and C1-C2 by Movement and Function. As always, consult with your treating healthcare provider prior to completing these exercises.



“A stiff custom-made collar was made for each patient; the instructions for use have been published earlier.”

Note:  Learning About Hard Cervical Collars from Alberta, Canada Health Network

What is a hard cervical collar?

A hard cervical collar supports your neck and limits your neck movement. This protects your spine.A hard collar works better than a soft one to limit your neck movement.

What is it used for?

A hard cervical collar is used for spine problems or injuries. It limits forward and backward movement more than a soft one does.Hard collars are usually only used after major surgery or a serious injury, such as a broken neck.You may get a hard cervical collar after you’ve used a halo brace. A halo brace attaches to your head. It provides very stiff support of your neck.

How do you wear a cervical collar?

A hard cervical collar fits from your chin to your breastbone (sternum). It extends from the base of your head down to the top of your back. Sometimes, the top of the collar fits tightly around the lower jaw.Your doctor can make sure that your cervical collar is the right size and fit. This will provide the best support for your spine.Some types of cervical braces cover more of your body. These braces limit your neck movement even more.It’s important to wear your neck brace or collar correctly. Wear it for as long as your doctor tells you.

What problems can happen from using a hard cervical collar?

Problems from using your collar can usually be treated by your doctor. They include:

  • Skin sores from pressure or moisture.
  • Trouble with balance and seeing where you are walking.
  • Weakness in your neck muscles.
  • Problems swallowing and eating.



“Practical aids, such as book rests were shown and recommended to the patients as part of their ergonomic education.” (*we image that today (2020s) cell phone, tablet and laptop holders may be added or replace book rests)



“In several cases local corticosteroids were injected into the painful muscle insertions in the occipital and neck areas, while muscular tension was also usually reduced by gentle massage….Corticosteroid injections were given to inflamed extremity joints in several cases.

(**Caution on corticosteroid injections:   “Corticosteroids constitute a double-edged sword – significant benefit with a low incidence of adverse effects can be expected if used in proper dosage and for a limited duration; however, wrong dose and/or duration and unmindful withdrawal after prolonged administration can have catastrophic effects.”)

“Disease-modifying medication was changed to more active therapy. ”



“The patients also participated in more general rehabilitation exercises, e.g. water gymnastics, etc.”


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