Pulmonary rehabilitation is one of the most effective treatments for breathlessness in chronic obstructive pulmonary disease (COPD), yet its effect is variable. While up to 60% of patients who complete a course of treatment see an improvement, that leaves 40% that do not. Understanding why it works for some and not for others can help personalise and improve treatment for COPD. This is what we’ve focused on in our most recent paper (preprint here) that will be published in the European Respiratory Journal.
A bit of background on how sensations are perceived. When we feel a sensation, our brains often both register and modulate the sensory information from the body. In fact, our sensory perception is probably quite dependent on how the brain processes incoming sensory information. This is influenced by what the brain thinks will happen and why. It is thought that previous experiences (called priors) create expectations in the brain about sensations, and that these are updated whenever the brain receives actual sensory information.
Below is a quote from a paper on how priors influence pain perception by Geuter et al. , explaining the concept so clearly I decided to reproduce it in its entirety:
All over the human body, there are receptors that help to alert the brain to potential harm. For example, intense heat on the skin elicits a signal that travels to the brain and activates many parts of the brain. Some of the same brain regions that are switched on by signals of potential bodily harm also help the brain to form expectations about events. A person’s expectations may have a strong influence on how they experience pain. For example, if a person expects that taking a pill will reduce their pain, they may feel less pain even if the pill is a fake.
Exactly how the brain processes pain signals and expectations remains unclear. Does the brain activity simply reflect how intense the heat is? Some scientists think there may be two separate processes going on: one that predicts what will happen and another that calculates the difference between the prediction and what the receptors actually detect. This difference is called a prediction error. If every unpredicted sensory signal elicits a calculation of the prediction error that would help improve the brain’s future predictions.
This system is open to manipulation. There are many factors that can adjust these priors or weight the incoming sensory information, causing the person to over- or under-perceive sensations. For example, anxiety and attentional bias may cause over-perception of sensations.
But how? How does this relate to COPD? In COPD, a prior may be formed linking shortness of breath to physical activity, for example climbing stairs. This prior, if bolstered by for example anxiety and attentional bias, may begin to dominate and cause over-perception of breathlessness. This means that breathlessness perception would be governed more by the prior and the anxiety/fear than by the input from the body. In this example, a simple flight of stairs become a cue for the brain to access its priors, which means generating an expectation of breathlessness and anxiety, all because that is what previous experiences have demonstrated will happen.
Pulmonary rehabilitation, however, challenges these priors. Rehabilitation makes the patient face their breathlessness, but in a safe healthcare setting. This may change the patient’s priors and how they process breathlessness-related cues. If this is the case, we may expect that patients with different priors show different treatment outcome, and we may expect that patients show a different response to cues after treatment than before.
But where? We know that predictions about bodily state and emotion (i.e. priors) are typically generated in a stimulus valuation network. This network consists of many brain regions, including the anterior insula, anterior cingulate cortex (ACC), orbitofrontal cortex and ventromedial prefrontal cortex. There are also more ‘downstream’ regions associated with breathing, including the posterior insula, which process incoming respiratory sensory information. These are responsible for sending sensory information from the body to other parts of the brain (both those dealing with the physical sensation and those processing the emotional impact such as the stimulus valuation network). The posterior insula, along with regions such as the angular gyrus and the supramarginal gyrus, are involved with how much attention a physical sensation gets. All of these regions might be likely places where pulmonary rehabilitation would change activation patterns.
What we did. We recruited 31 people with COPD and studied them before and after pulmonary rehabilitation. On each visit, we did the same tests: we collected a set of behavioural questionnaires (of which we used one, the Dyspnoea-12 , as our main measure of breathlessness); we did a lung function and an exercise test; and we did a functional brain scan (FMRI) to test their brain activity while they were looking at (and rating) breathlessness-related cues for anxiety (“How anxious would this make you feel?”) and breathlessness (“How breathless would this make you feel?”). *
Behavioural changes. The ratings of the patients were overall much lower for anxiety after rehabilitation, and this correlated with the main measure of breathlessness (Dyspnoea-12). The correlation was influenced by changes in depression in our patients, although we don’t know whether it is the depression that influences anxiety and breathlessness, the anxiety that influences depression and breathlessness, or the breathlessness that influences anxiety and depression. It may easily be that all of these factors influence each other. We do, however, know that they are linked. The figure below (Fig 1) shows how all the behavioural and physiological measures are correlated.
Fig 1. Correlation matrices of the measured behavioural variables. Abbreviations: wA, cue ratings of anxiety; wB, cue rating of breathlessness; StG, St Georges Respiratory score; Cat, Catastrophising score; Vig, Vigilance/Awareness score; Dep, Depression score; T Anx, Trait anxiety; S Anx, State Anxiety; Fat, Fatigue; BisBas, inhibition/activation scale; Spir, lung function (FEV1/FVC); ISWT, exercise ability (incremental shuttle walk test).**
While rehabilitation worked for the group as a whole, we saw that there was variability in the treatment response between patients. There was also no improvement in breathlessness ratings, nor was there any change in lung function in the group. Lung function was not linked to any of the behavioural measures, meaning that it isn’t a good measure of the impact of breathlessness in COPD.
Brain changes. Then we looked at how variation in brain activity explained the variation in our patients’ ratings of the cues over the course of their treatment. By looking at how variation in brain activity follows variation in ratings, we could make sure that even the patients that didn’t respond normally to treatment were included in the analysis. In other words, if a patient didn’t respond it is likely that their brain activation would not change either, and if a patient got worse we might see that their brain activation went in a different direction from those that got better. This gives us a much stronger idea of which areas get upregulated and downregulated (or stays the same) with successful treatment.
Looking at this variation, we saw that reduced breathlessness was linked with less activation in some brain regions (the anterior insula, ACC, posterior insula and supramarginal gyrus). This is a dampening in activity in brain areas handling expectations of breathlessness, and it could mean that successful treatment works by making patients re-evaluate their priors. Reduced anxiety was linked with greater activation in a slightly different set of brain regions (the posterior cingulate cortex, angular gyrus, primary motor cortex and supramarginal gyrus). As a set, these are involved with how much attention a physical sensation gets, and may be dampened by anxiety. In other words, if you are anxious, it is difficult to regulate how much attention you give a thing (i.e. if you are scared of spiders, you can’t just ignore one if you see one). So when we see an increase in these regions, this may mean that the patients are less anxious and more able to regulate attention. Taken together, this suggests that our patients had a more objective processing of breathlessness cues and were less dominated by their priors after rehabilitation.
Fig 2. Change in brain activity that fits with rehabilitation-induced changes in response to breathlessness cues (both for anxiety and for breathlessness). Blue colours mean lower brain activity, and red/yellow colours mean higher brain activity. **
Predicting treatment outcome. We also looked at whether brain activation before the treatment could predict who would benefit from the treatment and who would not. Several regions showed higher activation in those patients who went on to improve with treatment. These included the stimulus valuation network plus the primary motor cortex. Improvements in anxiety ratings were predicted by high activation in the ACC and ventromedial prefrontal cortex, which overlaps with one of our previous studies looking at breathlessness and anxiety in COPD patients versus healthy controls . These findings are also supported by a study that showed how higher fear levels before pulmonary rehabilitation tends to mean a greater response to treatment .
Fig 3. Brain activity before treatment that is linked with treatment outcome, both in terms of breathlessness (top) and anxiety (bottom). **
To conclude. Pulmonary rehabilitation seems to lead to reduced activity in the brain’s stimulus valuation network and increased activity in attention regulating networks. Those with strong responses in the stimulus valuation network before pulmonary rehabilitation typically see a bigger reduction in their responses to breathlessness cues after treatment. It may be that pulmonary rehabilitation works both by updating breathlessness-related priors and by reducing feelings of depression and anxiety that typically influence sensory processing. *** If this is the case, then we could improve treatment by focusing on re-learning priors, either by using drugs or alternative behavioural therapies. We could also use MRI as a way of developing behavioural tests (questionnaires, computerised tasks) that can be used to figure out who will benefit the most and in which way from the treatment.
 Geuter, S. et al. eLife 2017; 6:e24770
 Yorke, J. et al. Thorax 2010; 65: 21-26
 Herigstad, M. et al. Chest 2015; 148(4): 953-961
 Janssens, T. et al. Chest 2011; 140: 618-625
*The FMRI analysis used standard significant thresholds (cluster Z = 2.3, corrected cluster p = 0.05 corrected for multiple comparisons across the whole brain).
**Adapted from Herigstad et al, 2017, biorxiv: https://doi.org/10.1101/117390. The copyright holder for this preprint is the author/funder. It is made available under a CC-BY 4.0 International license
***In addition to potential improvements in fitness. We did see an increase in exercise capacity, even if none of the measured baseline physiological variables were changed, and it is possible that the rehabilitation causes the patients to become healthier and stronger.
The paper is available from here: http://biorxiv.org/content/early/2017/03/23/117390