Mobilization for spondylolisthesis

Hello!
I have a patient who is diagnosed L4 degenerative spondylolisthesis.
(Patient profile)
70 years old female. Aggravating activity is standing and walking.
She has a left buttock pain and squeezing feeling in left lateral area of leg and foot.
Left ankle reflex is absent. Motor loss is nil. There is a hypomobility in all the lumber spines.
I tried P-A mobilization for L5 spinous process protrusion and made her worse.
I wonder if any mobilization technique(tech.) as below are efficient for spondylolisthesis.
1. A-P mobilization in Maitland tech.
When PT mobilize L4 with A-P movement, can he move slipped vertebrae to posteriorly?
2. Test tech. of posterior lumber spine instability by David Magee
This is not described for a mobilization tech., but I wonder if it might be efficient.
(Procedure)
The patient sits on the edge of the table. PT stands in front of the patient. The patient places the pronated arms with elbows bent on the PT’s shoulders. The PT puts both hands around the patient so the fingers rest over the lumber spine and with the heels of the hands gently pull the lumber spine into full lordosis. To stress L5 on S1,the PT stabilize the sacrum with the fingers of both hands and asks the patient to push through the forearm while maintaining the lordotic posture. This produces a posterior shear of L5 on S1. In my case I wonder if it is effective to stress L4 on L5.

Thanks in advance.

Novice PT

Dear Novice PT

Spondylolisthesis is an absolute contraindication for manual mobilization techniques...the reason, spinal instability is too great, all spinal fractures of anyfom are a contraindication...please dont try any of these techniques on this patient

Cheers

Dear Dr.Damien

Thank you very much for your quick and kind reply.
I'll bear in mind your information from now on.
I am a novice of manipulative PT and of this forum,so I'm sorry I don't know how I should show my gratitude to you in this forum.

Novice PT

Perhaps you can also work on relieving exercises that assist flexion. This can assist a low grade spondylolithesis to reduce somewhat. Also if the general Lx and Tx are hypomobile then assisting those to get moving, whilst protecting the L4/L5 segment, will be of assistance to the patient. We all now that in this case the segment will not tolerate extension very well. But in fact the segments above still need to extend so that the amount of Ext on the L4/l5 is minisized. You can do all sorts of abdo exercises designed to maintain the lumbopelvic position whilst the other areas of the body move (e.g. Tx extension). So in other words think above and below the level to ask 'Is there something I can do here that will help minimize the forces on the problematic segment'.

And perhaps the last thing is that the vast majority of spondylo's are asymptomatic. Just because a client has one on x-ray doesn't always confirm that it is the cause of their symptoms :)

Dear Novice PT

Physiobob has given some really good advice and management plan, Please be sure of the severity of the condition/state of the verterbrae before trying to apply any manual therapy...
pain relief is what is meaningful to the client, any modalities within your expertise that gives this is what you should use...even if it requires pain medication...
Muscle spasm/tight spinal muscles can seem to mean hypomobility...if muscle spasm is reduced significantly, you should get better range without having to mobilize the joints...it is not easy to mobilize the joints of the elderly...issues with safetly (osteoporosis) and possibility of kissing spines makes this difficult...if you mobilzed L5 and made things worse, i would query an underlying fracture to be honest...

often foraminal stenosis, may be the reason for the problem not the spondylolisthesis it self...
can the patient lie on her back...? if she can can she be taught to pelvic tilt and hold...? if she cant lie down on her back flat, will hip flexion make it easier to cope? will the use of pillows make this easier...?

First are is the listhesis confirmed by imaging?

If not reassess to determine discal involvement or foraminal osteophytic encroachment.

If true listhesis try this:
Great article by PB O'Sullivan. Search more articles from him on his practices website or Google scholar.

http://www.bodylogicphysiotherapy.co...cises_2000.pdf

Hi Novice PT,

think youve had some great advice given already by physiobob and dr damien. I would go exactly with what physiobob said in getting Lx and Tx regions moving and extending to help take the pressure of extension off the L4/5 problematic area. To do this definitely go along the lines of dr damiens advice with gentle things like pelvic tilts utilising hip flexion and pillows given the patients age. I only reiterate this as its great advice and to try and take you away from the notion of manual mobs with this patient. Id suggest, if tolerated by the patient, using a foam roller to aid the Lx Tx extension which I find great for this.

Dear kind physios, Dr Damien, Physiobob, JayPhysio,yawsy123

My orthopaedist diagnosed stenosis which is not so sever by MRI and referred to me.
But flexion-ex. in spine position did not relieve her pain. So I hypothesized the main cause is not stenosis but spondylolistheis which is confirmed by x-ray and step sign.
The patient can lie on back but has a pain and pins & needles(intensity is 2/10).She has not time when pain and P&N is alleviated perfectly. She cannot tilt pelvic and hold at first.
The reason, I assume, may be hypomobility.
Today(7 th treatment) I treated the patient and found that lumbar lordosis is too excessive and that there is spasm over the left L1/2 to T10/11. I concluded main problem is lumber hypomobility as she couldn’t tilt pelvic without hip full flexion. She had no pain in flexion-ex today.
I cannot still decide which is the main cause, stenosis or lithesis. But I’ll proceed flexion-ex, thoracic mobilization to P.B.O’sullivan exercise.
Thank you very much for many helps. I am very impressed that I could have kind replies so quickly from all over the world.

Best,regards,

Novice PT