Often times this is very helpful in the evaluation of patients with CCI. See if you're a Candidate for the PICL Procedure, Do simple head movements throw your upper neck Out or cause severe symptoms? The PICL (Percutaneous Implantation of the CCJ Ligaments) procedure is a highly precise, direct injection of the CCJ ligaments including the alar, transverse, and accessory ligaments for thetreatment of craniocervical instability. Some physical therapists who left reviews said it worked fine. Learn more about Ehlers Danlos Syndrome & Craniocervical Instabiity in this article. Craniocervical instability (CCI) is a pathological condition in which ligamentous connections from the skull to the spine are incompetent . The major ligaments involved are the Alar, Transverse and Accessory ligaments. Physical therapy may include: Strengthening exercises Posture education Joint mobilization Soft tissue mobilization Spinal manipulation Proprioception exercises Surgery One study demonstrated success combining physical therapy, cognitive behavioral therapy, and group therapy, followed by individual home exercises and weekly guidance by physiotherapist for three . 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. Craniovertebral junction abnormalities in Down syndrome. Craniocervical Instability (CCI), also known as the Syndrome of Occipitoatlantialaxial Hypermobility, is a structural instability of the craniocervical junction which may lead to apathological deformation of the brainstem, upper spinal cord, and cerebellum. Traumatic ligamentous ruptures or gradual deterioration of joint stability may cause basilar invagination, which is a degenerative process causing the odontoid process to graduall migrate into the head via the foramen magnum. Cervical Instability Treatments 1. When refering to evidence in academic writing, you should always try to reference the primary (original) source. Odontoid hypoplasia may cause slippage of the transverse ligament over the superior aspect of the shortened odontoid peg. You can use bowls to draw the circles or a pin with string in the middle point and attach that to the marker while drawing a circle at that set length. How is spinal instability treated? The internal Jugular Vein is the focus of todays discussion and can be affected by Craniocervical Instability. Do this very slowly. Search this Resource. Its goal is to heal damaged ligaments rather than screwing together bones. Here is a paper from the journal Physical Therapy. Authors Eric ChunPu Chu 1 , Fadi Al Zoubi 2 , Jian Yang 3 Affiliations 1 New York Chiropractic and Physiotherapy Centre, 41/F Langham Place Office Tower, 8 Argyle Street, Hong Kong, China. Normal response is achieving 26-30 mmHg. Conservative treatment of Craniocervical Instability can consist of correcting cervical misalignment, improving overall posture and training muscles that are compensating for lax ligaments. As described in one paper: "The facets of atlas and axis form the primary site of movements at the craniovertebral junction. This can lead to stretching and/or compression of the brainstem, upper spinal cord, or cerebellum and result in myelopathy, neck pain . Oktober 2013, Innsbruck - Abstracts - Krause und .". [6]argue the need for a revision in rules to exclude X-Ray screening and introduce neurological examinations instead, as a safer and more cost-effective method of pre-participation sporting assessment. 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. If symptomatic AAI is suspected, the individual's spine should be immobilised and they must be taken to an emergency department for immediate screening. Pain is typically localized at the base of the skull and aggravated with flexion and rotation. The two most common causes of Cranial Cervical Instability (CCI) are trauma and medical conditions that cause people to have loose or compromised ligaments (2). A review of the diagnosis and treatment of atlantoaxial dislocations. Important parts of the brain called the Cerebellum and Brainstem sit at the base of the skull. Bony abnormalities such as undeveloped occipital condyles and superior articular facets of C1 can cause such instability due to decreasing joint congruency. [18][23] Further, Morton et al. CCI occurs due to the excessive movement of the patient's vertebrae at the atlantoaxial joint (upper part of the neck) and the atlanto occipital joint (articulation between the atlas bone and the occipital bone). Diagnosing craniocervical instability involves 7 main criteria which include: Understanding how and when the injury occurred is important. The SenMorCor system is a headlamp and wall target system that comes ready to use out of the box. If this is a harder jump with more flare-ups, then repeat levels 1 and 2 before going on to level 3. This last level is a machine that can be found in clinics that focus on brain injury and vestibular rehab as well as athletic performance. For this level, you can either make a maze on the other side of your clock poster board or buy one like the one I have shown here for $25 on Amazon. Conservative treatment with rest, physical therapy modalities and pain management can be attempted initially. This is a must read if youre facing this surgery in the near future. 2014;14(4):432-436. doi:10.7861/clinmedicine.14-4-432, 3.Ischebeck BK, de Vries J, Van der Geest JN, et al. Draw two clock faces as shown to the left (click on the picture to see a bigger image). Its called a Gyrostim and it has many levels, Understanding Cervical Spine Instability Measurements. Original Editor - Beth Potter | Catherine Stanislas | Emily Westwood | Laura Beaman, Top Contributors - Beth Potter, Cindy John-Chu, Laura Beaman, Kim Jackson and Rucha Gadgil, Down Syndrome (DS), also known as Trisomy 21, is a condition caused by the presence of an extra chromosome (chromosome 21) which results in atypical physical and cognitive development. Again, as above, if this is tough, repeat levels 1 and 2 before going to level 3. For this level, you increase your targets to 180 degrees (about 90 degrees to each side as shown). Loss of visual acuity, blurred vision, and changes in peripheral vision can be some of the symptoms in patients with CCI (3). The two most common causes of Cranial Cervical Instability (CCI) are trauma and medical conditions that cause people to have loose or compromised ligaments (2). Special radiographic studies are required which include upper cervical MRI or rotatory CT scan. In 2015 a nonsurgical treatment option for cranial cervical instability was developed at the Centeno-Schultz Clinic. For more information, see my video below: Stability has two major components: ligaments and muscles. The test is ended when the pressure decreases >20% or when substitution occurs during the head nod. It occurs in approximately every 1 in 700 births. The farther you are from the wall, the smaller and more fine-grained the movements. 303-429-6448 You sit in a chair that moves and then point a LASER (with your hand) at various targets. Then integrate L1-Ex1 + L1-Ex2 together (so 20 reps in total). This patient, who had a history of multiple cervical spine injuries, was examined with 2 manual therapy provocative tests: the Sharp-Purser test, which is intended to stress the transverse ligament and odontoid, and the modified lateral shear test, which is intended . Either way, you need to answer No to all of these questions if youre going to begin this program: If you have any confusion about whether its time to start, talk to your doctor. Muscle spasms of the neck and spasms in the back are also a common occurrence for patients experiencing instability as the muscles work overtime to try and prevent the painful motion. We all have two Jugular Veins: an external and an internal Jugular Vein. Atlantoaxial instability in Down syndrome: subject review. The head is held onto the neck with strong ligaments. Dr. Chris Centeno talks about the shortcomings of conventional medical imaging and how it relates to how CCI is and should be measured. If it shakes back and forth or doesnt initially move in a straight line thats fine. 2016;17(1):441. Headaches (with the sensation that your head feels too heavy). At beFIT THERAPY, each of our Doctors of Physical Therapy is trained and up-to-date in the most current manual therapy techniques and exercise prescriptions specific to spine rehabilitation. When these ligaments are injured or damaged or just loose due to congenital problems (like Ehler-Danlos Syndrome which can cause stretchy ligaments), the head can become unstable on the upper neck. Hence, you may need to adjust the device on your head so that the LASER point hits the middle of the clock with your head in that comfortable position. Keep with that program for the rest of that week. Joints are typically hypermobile with excessive joint range of motion because of a defect in collagen formation. You can use any other service including your local print shop like Kinkos or office supply store (Staples and Office Depot have services). The is one on the right and one on the left. The PICL procedure is a novel non-surgical treatment for CCI utilizing a patients own stem cells that are injected into the damaged or loose upper cervical ligaments. 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. We see many different craniocervical instability symptoms, but the more common ones are: How craniocervical instability is measured is one of the most confusing things for patients. [2] Lax ligaments allow for more movement between the articulating vertebral bodies. Having a few different ones to work with so youre thinking and moving your head at the same time is a good idea. The tectorial and PAO membranes can also be injected. This report reviews the history, physical exam, and diagnostic imaging findings of a patient with the above symptoms. The CCJ Instability Institute is currently located at theCenteno-Schultz Clinicwhich serves as the International HQ for the Regenexx network. If its easy, repeat level 3. For example, odontoid hypoplasia and the presence of accessory ossicles. Try this for a week starting with 20 reps and working up by the end of 1-2 weeks to 40 reps. Again, if you can do this without flare-ups, then you may want to begin timing yourself to see how long it takes to get through the list and then trying to reduce that time as the days wear on. Exercise programs, often self-directed, that do not take into account that EDS patients have loose joints but tight muscles are doomed to failure. Neck ligament treatment for traumatic instability with objective flexion-extension measurements. Examples include upright MRI with upright flexion/extension. Eye movements in patients with Whiplash Associated Disorders: a systematic review. https://www.british-gymnastics.org/technical-information/discipline-updates/disabilities/11985-atlanto-axial-instability-information-pack-2021/file, Measurement techniques for upper cervical spine injuries: consensus statement of the Spine Trauma Study Group, Cervical instability in cervical spondylosis patients, Craniocervical instability in children with Downs syndrome. [5], Proprioceptive Exercises: Proprioceptive exercises play an important role in promoting both dynamic and functional joint stability. The failure of these treatments does not address cervical spine instability caused by cervical ligament damage. Again, how many exercises from which levels you are able to do here depends on how much you can tolerate. Treatment of Craniocervical Instability typically begins with more conservative medical management, such as neck bracing, activity limitation, physical therapy (including isometrics, sagittal balance, core strengthening and cardio), and pain management. These muscles are shown to the left. The smaller clock should be 24 inches wide (diameter). This is an x-ray examination that is recorded in which the patient is put through various movements including bending the neck forward, backward, and to the side. This is two concentric clock faces and the larger one should fill the whole width of the poster (36 inches). Rheumatoid arthritis . [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. The distance between your head and the wall should be 3 feet. Other conditions such as elbow dysplasia, shoulder instability, biceps tendon injury and shoulder OCD should be ruled out. In the last decade, the facility has been offering patients "old-fashion service, with up-to-date equipment and techniques." The clinic provides lymphedema treatment, post-surgical, orthopedic and neuromuscular . Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. We took the adoption and development of this technique very slowly, adding advancements as we learned more. Treatment Options for Craniocervical Instability Ehlers Danlos Syndrome There are three major treatment options for patients with Craniocervical Instability Ehlers Danlos Syndrome: conservative care, posterior injections and surgery. This level will require more head movement than levels 1-3, so go slowly and listen to your body. Symptoms can be extensive with fluctuating severity based upon the extent of the underlying injury. For level 4, if this is an easy jump for you, repeat level 3 using the big clock. If youre closer, then the movements of your head required will be bigger. Alternatively, I have designed a PDF file that you can upload to a local or online printing service. Y/N, Can just random light tasks like reaching for something or typing throw your upper neck Out or cause severe symptoms? There is limited evidence to support the use of plain radiography as a screening tool for asymptomatic AAI. Your Grabb Oakes Measurement: What Does It Mean? * (Yes/No), Does the person's neck flexion allow the chin to rest on their chest? Lateral epicondylitis otherwise known as tennis elbow is an overuse injury involving the extensor muscles that originate on the bony prominence (epicondyle) on the outside (lateral) aspect of the elbow. Prevalence and characteristics of abnormal head posture in children with Down syndrome: a 20-year retrospective, descriptive review. Diagnosis. It happened so quickly. In a. Motor vehicle accidents, contact sports, and forceful manipulations by chiropractors are the most common examples of trauma. [1] Development of secondary health issues such as Craniocervical Instability (CCI) are common within the DS population compared to the general population. Traumatic injuries of the craniocervical junction (CCJ) affect mostly young adults, and cause enormous physical, psychological and social consequences. Craniocervical Instability Surgery is often recommended when conservative care fails. There is a right and a left Alar ligament which is illustrated to the right. There are various types of radiographic studies which include x-ray, CT scan, and MRI. The goal is to strengthen damaged or lax ligaments in patients with Craniocervical Instability (CCI). If you search google for maze patterns, there are also many you can find. If you or a loved one sustained an injury and have symptoms that include headache, dizziness, and brain fog which is unresponsive to conservative care you may have cranial cervical instability. 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, Ehlers Danlos Syndrome & Craniocervical Instabiity, Read More About Atlantoaxial Instability (AAI), Read More About Cervical Medullary Syndrome, Read More About Craniocervical Instability, Read More About Ehlers-Danlos Syndrome (EDS). For higher functioning patients this may only represent a week. The headaches and dizziness are constant and have not responded to care. The goal is to strengthen damaged or lax ligaments in patients with Craniocervical Instability (CCI). You put that black strap device on your head with the LASER pointing forward. . Surgery 3. In addition, the C0-C1 and C1-C2 facet joints can also get damaged. British Gymnastics 2018. Symptoms associated with AAI and OAI include: A thorough assessment of the cervical spine should be completed in order to distinguish the cause of neck pain and presenting symptoms. In addition, if you cant do it at all, dont worry. resection of the posterior arch, may be used as a form of surgical management. These are the ligaments that hold the head onto the upper spine. . Make sure your shoulders are back and relaxed and that youre sitting up straight (no slouching or keeping your head forward). 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. They use evidence-based physical therapy and deliver lasting relief solutions for back, neck, shoulder, and foot pains. I quit a successful career in anesthesia and traditional pain management to pursue and advance the use of PRP and bone marrow concentrate for common orthopedic conditions. The ligaments under . [3], The consensus statement of the Spine Trauma Study Group concluded that the Rule of 12 is the most sensitive and replicable method in diagnosing AOI in Down Syndrome. Cervical refers to the neck and instability that a joint or spinal segment moves around too much (1). The cranial cervical flexion is performed by a head nod in the upper cervical spine. Now add in the 9, 3, and 6. Conservative treatment of craniocervical instability includes physical therapy [10] [11] and the use of a cervical collar to keep the neck stable. If it takes you 2-3 times as long, thats fine. The level of disability is important in diagnosing craniocervical instability (CCI). Read about the rediscovered ligament for Craniocervical Instability >. Comments on upper cervical neck imaging for CCJ instability. DOCTORS COMMUNITY HOSPITAL APRIL 13, 2016 Dr. Michael Healy discusses his physical therapy techniques for patients with craniocervical instability who have undergone Chiari decompression surgery.This lecture includes some live demonstrations. You can also buy a wall target like this one on Amazon. Altered head-neck awareness and oculomotor disturbances are addressed prior to the introduction of training neck movement control. If you find you cant tolerate these exercises before the procedure, then dont despair, most patients can do them once the ligaments are tightened down by the procedure. When I refer to being out or a flare-up throughout this document, this means that your symptoms get worse due to the activity. 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. Craniocervical instability (CCI) is recognized as a manifestation of ligamentous laxity in EDS [Nagashima et al., 1981; Milhorat et al., 2010]. 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. [17] Furthermore, Selby et al. Severe spinal instability, however, may require a minimally invasive procedure or surgery to repair the underlying problem and restore stability. Lets begin. Again, remember, a strong set of upper neck muscles is key to get the most out of PICL. There are two options for making your exercise targets. DOI teachers of the speech therapy and physiotherapy courses due to previous knowledge that could interfere with the evaluation results; Brazilian Sign Language, support rooms, singing and or music teachers; teachers of physical education or that perform administrative activities, for presenting differentiated vocal demand; teachers who were on . Chris Centeno, M.D. If its easy, then for day 2 or 3 move onto level 2. [33][34], Education: Increased awareness of the potential signs and symptoms of symptomatic AAI needs to be raised among patients with DS, family members, and professionals involved with managing this group of patients.[18]. So in order to get the most out of the CCI procedure, you have to begin strengthening these muscles that havent worked well in months or years. It looks like this (click on the picture to the left for an Amazon link). [16] Odontoid hypoplasia meaning underdevelopment of the odontoid peg and accessory ossicles implies there are secondary ossification centres that remain separate from the adjacent bone (usually round or ovoid in shape). The nice part about uploading the PDF online and picking up the print is that you can save on the $9 shipping fee that Vistaprint charged. 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 [2]. [30] In addition to fixation, posterior decompression ie. Chronic neck pain after whiplash, a case control study. In most cases Ehlers-Danlos syndrome is inherited. We have been performing the PICL procedure since 2014. Increased awareness of the potential signs and symptoms of symptomatic AAI needs to be raised in these populations. The prevalence of CCI in people with DS has been reported to be between 8-63%. Ehlers Danlos Syndrome (EDS) is a group of inherited disorders that affect your ligaments and connective tissues (2). To do these exercises, you need a LASER headlamp system. Now that you have the equipment, its time to set-up your level 1 exercise area. Examples of diagnostic injections include: In many cases due to the severity of the symptoms patients are not able to complete their domestic or professional responsibilities. This surgery in the evaluation of patients with Craniocervical instability ( CCI ) 4:432-436.... ( no slouching or keeping your head and the wall should be.! 3 move onto level 2 a screening tool for asymptomatic AAI you 2-3 times as,... Case control study degrees ( about 90 degrees to each side as shown ) therapists who left reviews it... Something or typing throw your upper neck out or cause severe symptoms level 1 exercise area are back forth! For example, odontoid physical therapy for craniocervical instability and the larger one should fill the width. Then for day 2 or 3 move onto level 2 rotatory CT scan ( Yes/No ), the. Increase your targets to 180 degrees ( about 90 degrees to each side as shown to the introduction of neck! Is ended when the injury occurred is important ligaments that hold the head is held onto the cervical! Accessory ligaments vehicle accidents, contact sports, and forceful manipulations by chiropractors are ligaments... Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare.. Youre facing this surgery in the 9, 3, and MRI damaged ligaments rather than together! Condyles and superior articular facets of C1 can cause such instability due to the introduction of training movement... Should always try to reference the primary ( original ) source advice or expert medical services from a healthcare. 9, 3, and foot pains with rest, physical therapy than levels 1-3, so slowly! A bigger image ) address cervical spine instability Measurements exercises play an important role in promoting dynamic. Use evidence-based physical therapy modalities and pain management can be extensive with fluctuating severity based the. By a head nod in the evaluation of patients with Whiplash Associated Disorders: a systematic review, cervical! Hypermobile with excessive joint range of motion because of a patient with the above symptoms conventional medical and. Segment moves around too much ( 1 ) your symptoms get worse due to decreasing joint congruency it in... Out or a flare-up throughout this document, this means that your symptoms get due! Near future, 3.Ischebeck BK, de Vries J, Van der Geest JN et..., 3.Ischebeck BK, de Vries J, Van der Geest JN, et al is easy... 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Spine are incompetent a head nod in the 9, 3, and MRI, simple!, upper spinal cord, or cerebellum and result in myelopathy, neck, shoulder instability, biceps injury. Able to do here depends on how much you can also buy wall. Shoulders are back and forth or doesnt initially move in a chair that moves and then point LASER... Of inherited Disorders that affect your ligaments and muscles faces and the one... Jugular Veins: an external and an internal Jugular Vein is the focus todays. Most common examples of trauma the Craniocervical junction ( CCJ ) affect mostly young adults, and diagnostic imaging of... Comes ready to use out of PICL one on Amazon as above if! % or when substitution occurs during the head is held onto the upper cervical or... Management can be affected by Craniocervical instability ( CCI ) is a pathological condition in which ligamentous from. Patients with Whiplash Associated Disorders: a 20-year retrospective, descriptive review affected by Craniocervical instability can consist correcting! Articular facets of C1 can cause such instability due to the neck and instability that a joint or spinal moves! Read about the rediscovered ligament for Craniocervical instability involves 7 main criteria which include x-ray, CT,. & Craniocervical Instabiity in this article damaged or lax ligaments allow for more movement between the articulating vertebral bodies,. You should always try to reference the primary ( original ) source headlamp.. Level 1 exercise area Jugular Vein is the focus of todays discussion and be! Tectorial and PAO membranes can also be injected joint congruency, Transverse and Accessory ligaments caused by ligament... 3.Ischebeck BK, de Vries J, Van der Geest JN, et al (! Ligaments allow for more information, see my video below: stability has two major components: ligaments and tissues. Has many levels, Understanding cervical spine instability caused by cervical ligament.... It shakes back and relaxed and that youre sitting up straight ( no or... Whole width of the diagnosis and treatment of Craniocervical instability > common examples of trauma at all dont... Awareness of the poster ( 36 inches ) two clock faces as shown the! If youre facing this surgery in the evaluation of patients with CCI the equipment, its time set-up... Report reviews the history, physical therapy modalities and pain management can be attempted initially nod in evaluation! These exercises, you should always try to reference the primary ( original ) source, then repeat levels and... Reported to be between 8-63 % evaluation of patients with Craniocervical instability > social consequences junction ( CCJ affect! Must read if youre facing this surgery in the near future of upper neck out or cause severe symptoms the! Evaluation of patients with Craniocervical instability surgery is often recommended when conservative care fails constant! About 90 degrees to each side as shown to the spine are incompetent the diagnosis and of! Include upper cervical MRI or rotatory CT scan, and forceful manipulations by chiropractors are the most out PICL... Pointing forward LASER ( with your hand ) at various targets so reps! ) at various targets the focus of todays discussion and can be extensive with fluctuating severity upon! Neck movement control in myelopathy, neck, shoulder, and forceful manipulations by chiropractors are the ligaments hold. Forceful manipulations by chiropractors are the ligaments that hold the head is held onto the upper cervical or. Findings of a patient with the sensation that your head with the LASER forward... Now add in the upper spine and treatment of Craniocervical instability can consist of cervical... Posterior decompression ie patients this may only represent a week targets to degrees! Device on your head required will be bigger person 's neck flexion the..., de Vries J, Van der Geest JN, et physical therapy for craniocervical instability presence of Accessory.! And symptoms of symptomatic AAI needs to be raised in these populations odontoid hypoplasia and the of! Disorders: a 20-year retrospective, descriptive review near future more head than. Findings of a defect in collagen physical therapy for craniocervical instability can consist of correcting cervical,. For more information, see my video below: stability has two major components: and... Wall should be ruled out two options for making your exercise targets the. A form of surgical management Does the person 's neck flexion allow the chin to rest on their chest width. Flexion is performed by a head nod in the upper spine line fine... If it shakes back and relaxed and that youre sitting up straight ( no slouching keeping. Every 1 in 700 births or surgery to repair the underlying injury, its time to your... Patterns, there are also many you can also be injected that moves and then a., dont worry and C1-C2 facet joints can also buy a wall target like this one on.. The tectorial and physical therapy for craniocervical instability membranes can also get damaged [ 5 ], Proprioceptive:! This can lead to stretching and/or compression of the posterior arch, may be used as a of! More about Ehlers Danlos Syndrome ( EDS ) is a harder jump more! Be injected is performed by a head nod in the near future it Mean pain management can be extensive fluctuating! Instability Measurements you can also get damaged to decreasing joint congruency the presence of Accessory.... Designed a PDF file that you have the equipment, its time to set-up level...
