12/1/2015
Objectives
Neurophysiological
Facilitation of Respiration
Dr.Nidhi Ahya (Asst Prof)
MPT-Cardio-vascular & Respiratory PT(Critical Care)
Introduction
• PNF of Respiration is a terminology used to describe
externally applied proprioceptive and tactile stimuli that
produce reflex respiratory movement responses and
appear to alter the rate and depth of breathing
• Developed empirically for treating unconscious patients
in neurological ICU at Victoria Hospital in London by
Delva D Bethune in 1975
Responses
• The proprioceptive & tactile stimuli selected can produce
remarkably consistent reflexive responses in the
ventilatory muscles and overall respiratory function
Inspiratory expansion of the ribs
Increased epigastric excursion
Increased tone in the abdominal muscles
Change in RR (usually lower)
Involuntary coughing
Correction of altered breathing pattern
Increase in level of consciousness
• To understand the application of various techniques of
proprioceptive neurophysiological facilitation for
improvement in respiratory mechanics and ventilation
2
• Normal rate of spontaneous breathing is 12-18
breaths/min
• It includes involuntary spontaneous deep breaths
called as ‘sighs’ every 5 – 10 min in the ventilatory
cycle
• Various experiments to study the development of
atelectasis have shown that this alteration in depth of
breathing is essential to prevent collapse of alveoli.
• Unconscious patients- Monotonous shallow breathing
- inadequate ventilation - Atelectasis
3 4
• These effects appear to be cumulative
• Successive application of stimuli elicit faster responses
& longer retention of the altered pattern
• Changes during treatment are dramatic, but may last
only for a short time period after application of
stimulus
• Pronounced responses seen in more deeply comatose
patients, although responses are also elicited in
conscious patients
5 6
1
 12/1/2015

Techniques Perioral Stimulation

• Perioral stimulation
• Vertebral pressure ( Upper & lower thoracic)
• Anterior stretch basal lift  Method:
• Co-contraction of abdomen • Firm pressure is applied &
• Intercostal stretch maintained to the patient’s
• Maintained manual pressure (moderate) upper lip
• Facilitation/Inhibitory techniques for accessory • Caution: Not to occlude
muscles of ventilation nasal passage

7 8

 Response: • Pressure is maintained till the desired effects are

required
• The response is a brief episode of apnea (5 sec)
• RR is usually reduces
followed by increased epigastric excursion
• Sighing may sometimes be observed
• Initial response: Large maintained epigastric swell
• Snout / mouth / lip Phenomena – pursed lips may be
• As the stimulus is maintained, epigastric excursion may seen
increase so that the movement is transmitted to upper
chest and patient appears to be ‘deep breathing’ • In unconscious patients if mouth is open it closes and
swallowing and sucking is observed even in presence
9 of oral airways 10

 Mechanism: Vertebral pressure

 Method:
• The responses seen are consistent with observations of • Firm manual pressure
Peiper in studying the neurology of sucking, is directly applied
swallowing and breathing &T2-T5 (upper
• Central Pattern Generator for sucking is located in thoracic vertebrae)
medulla where respiratory neurons also are located T7-T10 ( lower
• Possibly the respiratory effect is due to the activation thoracic vertebrae)
of primitive reflex of sucking • Pressure should be
• But the mechanisms that generate its rhythms are not maintained for few
well understood seconds
11 12

2
 12/1/2015

• Pressure applied with open hand for comfort  Mechanism:

• Firm enough to cause intrafusal stretch
• Given in Supine position ( so body stabilization not
needed & changes can be monitored • The corresponding expansion seen might be because of
activation of dorsal intercostal muscles
• The pressure applied stretches the intrafusal fibers thus
 Response:
activates the Dorsal root mediated inter -segmental
reflex which leads this response
• T2 – T5 pressure increases epigastric excursions &
deep breathing
• T7-T10 increases respiratory movements of apical
thorax
13 14

Anterior stretch basal lift  Response:

Method: • Increased movement of the ribs and lateral expansion

• Patient in supine
• Hands under posterior ribs • Expansion of posterior basal area
• Ribs lifted upward gently and
maintained • Increased epigastric movements
• Can be given U/L or
bilaterally

15 16

Co-contraction of Abdomen
 Mechanism:

• Stretch on the dorsal IC area also stretches the IC of Method:

mid- thoracic ribs • Rood – 1973
• Pressure simultaneously over
• Dorsal root mediated inter -segmental reflex lower lateral ribs and pelvis
(Ilium)
• Activation of diaphragm by IC afferents • Right angles to patient
• Alternate right and left sides
• Moderate force
17 18

3
 12/1/2015

 Response: Mechanism:

• Increased epigastric movements • Increased abdominal tone & activation of coastal

fibers of the diaphragm
• Increased muscle tone & contraction of rectus • Pressure across abdomen – intrafusal stretch on
abdominus opposite side muscle –activates homonomous
extrafusal muscles of same side
• Increased firmness on palpation • Stretch- Contract-Stretch-Contract continues till
pressure is maintained
• Coughing if retained secretions are found • Stretch receptors activation improves chest expansion
on contralateral side
19 20

Intercostal stretch • The application of the stretch is timed with exhalation

and the stretched position is maintained as the patient
Method: continues to breath

• May be done unilaterally / bilaterally

• Stretch maintained over
the upper border of rib in
a direction that will widen Response:
the IC space above it.
• Gradual increase in inspiratory movements in and
around the area being stretched
• Pressure applied in a
downward direction, not
pushing inward into the • When done over unstable areas as in paradoxical
movement of upper rib cage / decreased mobility
patient 21 – normal pattern is restored 22

Maintained Manual pressure

Caution:
• Not to be given on fractured or floating ribs Method:
• Care in mammary tissue in females • Firm contact of open hands is maintained over the area
in which expansion is desired
Mechanism:
Response:
• Intercostal stretch receptors stimulation • Gradually increased excursion of the ribs under the
• Reflexive activation of the diaphragm by the intercostal contact area
afferents that innervate its margins • Useful in painful situations
• Most effective technique to reduce RR when firm
23 contact maintained over anterior costal margin 24

4
 12/1/2015

Mechanism: Facilitatory/Inhibitory Techniques

• Inspiratory response is thought to be due to cutaneous
tactile receptors
• Local cutaneous stimulation of the thoracic region
would then tend to reflexly produce an inspiratory
position of the rib cage, therby increasing the TV
over several breaths and thus helps in reducing RR
25
• After giving proper instructions and facilitation of
preferred breathing pattern if patient is not
demonstrating an optimal breathing pattern, then
specific facilatation and inhibitory techniques can be
used
• These should be initiated for the accessory muscles of
ventilation.
26

• Methods: • Position:
In P.N.F. positioning continues to be single most
Pectoralis facilitation
important aspect of all ventilatory facilitation
Sternocledomastoid and Scalene facilitation
techniques
Upper Trapezius facilitation
Example
Counter rotation ( Butterfly technique )
 Slightly posterior tilted pelvis tends to facilitate
diaphragmatic breathing .
 Where as slightly anterior tilted pelvis facilitate
upper chest breathing .
27 28

Pectoralis Facilitation Butterfly Technique

29 30

5
 12/1/2015

Counter-Rotation Technique
Clinical Application
• Assessment of vital parameters, breathing pattern,
respiratory rhythm, thoracic excursion, and
auscultation should be done before and after treatment
• Patient’s response determines the duration of
treatment
• Procedure of choice is used till the desired effects are
achieved
• Patient’s responsiveness might improve – flutter eye
lids, turn head, push therapist’s hand away etc
31 32

Summary Reference
• Use of tactile and proprioceptive stimulus to improve • International Perspectives in Physical Therapy
respiratory mechanics Respiratory Care- Jennifer Pryor & Barbara Webber
• Response is observed better in deeply comatose
patients
• Response does not sustain for a long time
• It is cumulative to a repeated stimulus applied over a
period of time.
• Responses might not be consistent i.e. may vary from
patient to patient
33 34

Questions
 3 Marks
• Name any 3 techniques of neurophysiological facilitation
of respiration
• Enlist the type of responses expected after application of
neurophysiological facilitation of respiration
• Butterfly counter-rotation

 7 Marks
• What is neurophysiological facilitation of respiration?
Explain the method, responses and mechanism of any two
techniques in detail 35 36

6
 12/1/2015

Reference
• International Perspectives in Physical Therapy
Respiratory Care- Jennifer Pryor & Barbara Webber

37