CVR Physiotherapy › Technique cards › Breathing and breathlessness
Neurophysiological facilitation and PNF of respiration
Facilitation of breathing was asked three times as 7 marks, all recently: neurophysiological facilitation of respiration (W22), three PNF techniques for facilitation of respiration (W24) and PNF techniques to improve lung expansion (S25). NPF works on patients who cannot follow commands; PNF works on patients who can.
- Syllabus
- Ch 4(g) Neurophysiologic facilitation of respiration; practical: PNF for breathing facilitation and inhibition
- Priority
- Rising. In 3 of 20 papers (2016–2026), all since 2022.
- Asked as
- 7m W22W24S25
- Usual split
- 7-mark description of techniques with application and response
- Checked against
- Bethune's description of neurophysiological facilitation (1975) as summarised in later studies; recent clinical studies in ventilated and stroke patients; PNF principles (Adler, Beckers and Buck). Full list under Sources.
- Content checked
- 19 October 2026. Next review due October 2027.
- My revision
-
1Neurophysiological facilitation (NPF): what it is
Neurophysiological facilitation of respiration uses external touch and pressure (proprioceptive and tactile stimuli) to produce reflex changes in breathing: deeper breaths, more movement in a chosen area, and changes in rate. It was described by Bethune (1975) for unconscious adults.
- Who: patients who cannot follow instructions: unconscious or sedated (including ventilated patients with some own breathing), after head injury or stroke, confused patients, young children.
- Aims: increase depth of breathing and lung expansion, improve basal and segmental ventilation, help secretions move, improve oxygenation.
- Dose: each technique held through several breaths (often 30 seconds to a minute), repeated as long as a good response is seen; watch breathing, SpO₂ and heart rate.
2NPF techniques (7 marks in W22)
| Technique | How to apply | Response seen |
|---|---|---|
| Perioral pressure | Firm, maintained pressure with a finger on the upper lip, between the nose and the lip | More movement of the upper abdomen, deeper breaths, sighing; mouth closure and swallowing (linked to the sucking reflex) |
| Intercostal stretch | Pressure on the upper border of a rib, pushing it down to widen the intercostal space above; hold through several breaths | More expansion of the stretched area (intercostal stretch reflex) |
| Vertebral pressure | Firm pressure over the upper thoracic (about T2–T5) or lower thoracic (about T7–T10) spinous processes | Upper level: more upper-abdominal movement and deeper breathing. Lower level: more upper-chest (apical) movement |
| Co-contraction of the abdomen | Pressure on the lower ribs and the pelvis on one side, drawing them towards each other | More upper-abdominal movement and posterior basal expansion; firmer abdominal wall |
| Anterior stretch basal lift | Patient supine; the therapist's hands under the lower posterior ribs lift them gently upwards and hold | Posterior basal expansion and upper-abdominal movement |
| Maintained (moderate) manual pressure | Firm, steady hand pressure over an area of the chest wall | More movement under the hand during breathing in |
Precautions: no pressure techniques over fractured ribs or an unstable spine, osteoporosis, painful wounds or burns; stop if the patient becomes agitated, the heart rate or BP becomes unstable, or SpO₂ falls. In raised intracranial pressure keep handling short and gentle.
Evidence: small studies in ventilated, stroke and paediatric patients show short-lasting improvements in breathing pattern, chest expansion and some gas-exchange measures. The effects last minutes, so NPF is used together with positioning and other techniques.
3PNF for respiration (7 marks in W24 and S25)
Proprioceptive neuromuscular facilitation (PNF) applies the same principles used for limbs (manual contacts, stretch, resistance, verbal commands, irradiation from strong patterns) to the breathing muscles, in patients who can co-operate.
| Technique | How to apply | Effect |
|---|---|---|
| Repeated quick stretch with resistance | Hands on the lower lateral ribs (or upper abdomen for the diaphragm); a quick stretch inwards and downwards at the end of expiration, then light resistance through inspiration; repeat the stretch during the breath in ("breathe in, push my hands out") | Stretch reflex recruits the intercostals or diaphragm; more expansion of that area |
| Upper-limb D2 flexion pattern with inspiration | Bilateral D2 flexion (arms move up and out, as if reaching overhead) while breathing in; return in D2 extension while breathing out; can be resisted | Irradiation from strong arm and scapular muscles; lifts and expands the upper chest |
| Trunk lift and chop | "Lift" pattern (diagonal upward reach with trunk extension and rotation) with inspiration; "chop" pattern (diagonal downward with trunk flexion) with expiration | Trunk extension opens the chest for inspiration; flexion helps expiration and coughing |
| Scapular posterior elevation with inspiration | Side-lying; resisted scapular posterior elevation as the patient breathes in | Upper-chest and lateral expansion |
| Rhythmic initiation | Passive, then active-assisted, then active and resisted breathing movement in a rhythm | Teaches a coordinated breathing pattern in patients who cannot start the movement |
| Approximation and timing for emphasis | Compressing the ribs at end-expiration before the breath in; holding a strong pattern while emphasising the weaker area | Facilitates expiration and directs expansion to the weak area |
For "three PNF techniques" (W24): write repeated quick stretch with resistance, bilateral D2 flexion with inspiration, and the trunk lift and chop, each with the method and the effect.
Indications: weak or uncoordinated breathing after stroke, spinal cord injury and neuromuscular disease; post-operative and post-ICU patients with low lung expansion; collapse at a lung base. Precautions: rib fractures, fresh wounds and drains under the hands, pain, unstable cardiovascular status.
4Exam corner
Past questions (MUHS, 2016–2026)
- 7-mark questionsWhat is neurophysiological facilitation of respiration? (W22). Any three PNF techniques for facilitation of respiration (W24). PNF techniques to improve lung expansion (S25).
Answer skeleton: NPF, 7 marks
- [1] Definition and who it is for (cannot follow commands).
- [4] The six techniques: application and response (a table).
- [1] Aims and dose.
- [1] Precautions and contraindications.
Test yourself
3 mName six NPF techniques.
Perioral pressure; intercostal stretch; vertebral pressure (upper and lower thoracic); co-contraction of the abdomen; anterior stretch basal lift; maintained manual pressure.
MCQPerioral pressure is applied:A. Over the sternumB. On the upper lip between the nose and lipC. Over T7–T10D. Under the posterior ribs
B. Firm, maintained pressure on the upper lip.
MCQWhich PNF limb pattern is paired with inspiration to expand the upper chest?A. D1 extensionB. D2 flexionC. D2 extensionD. Chop
B. Bilateral D2 flexion lifts the arms up and out with the breath in.
Sources
- MUHS BPTh syllabus (2012) and MUHS IV BPTh question papers 2016–2026 (muhsonline.com, unofficial archive; Dhole Patil College of Physiotherapy past-paper page).
- Bethune D. Neurophysiological facilitation of respiration in the unconscious adult patient. Physiother Can 1975;27:241–5.
- Immediate effects of perioral pressure and intercostal stretch in mechanically ventilated patients: a randomised crossover pilot study (University of Benin Teaching Hospital). International Journal of Medicine and Medical Research.
- The effects of neurophysiological facilitation techniques on respiration in stroke patients (randomised trial, registered as NCT05601934). Impact of neurophysiological respiratory facilitation techniques on arterial blood gas parameters in paediatric patients with bronchial pneumonia. Bull Fac Phys Ther 2026.
- Adler SS, Beckers D, Buck M. PNF in Practice: An Illustrated Guide (patterns, techniques and their use for breathing).
- Structure and classical content: Frownfelter & Dean (2022), chapter on facilitating ventilation patterns.
Educational notes for exam preparation. Not medical advice.
Version 1. Content checked 19 October 2026. Next review October 2027.