Neurophysiological facilitation (NPF)

Neurophysiological facilitation (NPF)

·         Neurophysiological facilitation of respiration is reflex respiratory movement responses that alter rate and depth of breathing through externally applied propioceptive and tactile stimuli.

·         D L Bethune developed this technique while working with unconscious patients.  Nowadays widely used in unconscious and conscious patients.

Facilitatory stimuli

The tactile and prorioceptive stimuli used in treatment are designated as follows  

1.      Perioral pressure

2.      Intercostal stretch

3.      Vertebral pressure ( upper thoracic and lower thoracic)

4.      Anterior stretch-lifting of posterior basal area

5.      Manual pressure

Application of these stimuli results in (response=reflex)

1.      Visibly deeper respiration-larger expansion of ribs and increased epigastric excursion

2.      Increased and palpable tone in the abdominal muscles

3.      Change in respiratory rate

4.      Involuntary coughing

5.      Normal respiratory pattern

6.      Mechanical stability

7.      Change in breath sounds on auscultation

8.      Retension of improved respiratory function

Indications

      Unconscious/non-alert patients

·         Post-surgical patients

·         Neurological patients

·         Children

·         Patient who cannot complete deep breathing volitionally

  

Procedure

·         Chest auscultation and usual assessment procedure should be completed before and after treatment

·         Patient should be assisted during treatment to gauge the response and help determine treatment duration

·         Apart from propioceptive and tactile stimuli, visual and auditory feedback are also used in appropriate patients

·         All patients don’t necessarily respond to all facilitation stimuli. It the desired response is not obtained by one technique then the technique will be discarded and another is attempted.

Fig: A. Intercostal stretch- pressure down towards the next rib, not ‘in’ towards the patients back. B. Vertebral pressure. C. Lifting posterior basal area. D. Perioral stimulation: moderate pressure on top lip. E. Co-contraction of abdominal muscles: pressure over lower rib and pelvic bone. 

Procedure	Method	Observation	Suggested mechanism
1. perioral stimulation	Pressure is applied to the patient’s top lip by the therapist’s finger- and maintained	# Increased epigastric excursion # Deep breathing # Sighing # Mouth Closure # Swallowing # Snout phenomena	Primitive reflex response related to suckling
2. Vertebral pressure high	Manual pressure to thoracic vertebrae in region of T2-T5	# Increased epigastric excursion # Deep breathing	Dorsal root-mediated intersegmental reflex
3. Vertebral pressure low	Manual pressure to thoracic vertebrae in region of T7-T10	Increased respiratory movement of apical thorax
4. Anterior stretch- lifting posterior basal area	# Patient supine # Hands under low ribs # Ribs lifted upward	# Expansion of posterior basal area # Increased epigastric movement	# Dorsal root as above # Stretch receptor in intercostals, back muscles
5. Co-contraction-abdomen	# Pressure laterally over lower ribs and pelvis # Alternate right and left side	# Increased epigastric movement # Increased muscle contraction (rectus abdominus) # Increased firmness to palpation # Depression of Umbilicus	Stretch receptor in abdominal muscles. Intercostals to phrenic reflex
6. Intercostal stretch	Stretch on expiratory phase maintained	Increased movement of area being stretched	Intercostal stretch receptors
7. Moderate manual pressure	Moderate pressure open palm	Gradually increased excursion of area under contact	Cutaneous afferents