Alcoholism: Clinical and Experimental Research

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Publication history
Published article online:
17 Sep 2007
Issue online:
17 Oct 2007
Received for publication November 15, 2006; accepted July 13, 2007.
Tables & Images
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Fig. 1 Reaction time (left) and movement time (right) Fitts' task.
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Table 1. Demographic, Cognitive, and Substance Use Variables
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Table 2. Fitts' Task—Reaction Time (RT) and Movement Time (MT) for Large and Small Targets
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Alcoholism: Clinical and Experimental Research
Volume 31 Issue 11 Page 1820-1825, November 2007
To cite this article: Bieke De Wilde, Geert Dom, Wouter Hulstijn, Bernard Sabbe (2007)
Motor Functioning and Alcohol Dependence
Alcoholism: Clinical and Experimental Research 31 (11), 1820-1825.
doi:10.1111/j.1530-0277.2007.00484.x
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Motor Functioning and Alcohol Dependence
• Bieke De Wilde,
• Geert Dom,
• Wouter Hulstijn, and
• Bernard Sabbe
• From the Psychiatrisch Centrum Broeders Alexianen (BW, GD), Boechout, Belgium; and Collaborative Antwerp Psychiatric Research Institute (CAPRI), (BW, WH, BS), Antwerp, Belgium.
Reprint requests: Bieke De Wilde, MA, Psychiatrisch Centrum Broeders Alexianen, Tav Bieke De Wilde (afdeling 1), Provinciesteenweg 408, 2530 Boechout, Belgium; Fax: 0032-3-460-15-57; E-mail: [email protected]

Abstract
Background: Autopsy and neuroimaging research in stably abstinent alcoholics illuminated structural and functional abnormalities in brain areas that organize and coordinate motor functioning. Researchers that used behavioural tasks to measure motor functioning found that abstinent alcoholics perform worse than healthy controls. These researchers however did not analyze timed responses into their cognitive and motor components. They thus were unable to decide which aspects of information processing are impaired. We here used a Fitts' task to examine differences in cognitive and motor components between abstinent alcoholics and healthy controls.
Methods: Fifty-two abstinent alcoholics and 52 healthy controls participated in this research design. Fine motor functioning was assessed by means of the Fitts' task.
Results: Abstinent alcoholics needed more time to perform timed responses than healthy controls. As both reaction and movement times were higher in abstinent alcoholics, both cognitive and motor processes seem to be impaired. When the task became more difficult (small targets instead of large targets) abstinent alcoholics needed proportionally more time to give the correct response than healthy controls. This phenomenon solely applied to movement times.
Conclusions: These research data indicate that abstinent alcoholics are somewhat impaired on a behavioral level. The execution of timed responses indeed was lengthier in abstinent alcoholics than in healthy controls. As both cognitive and motor processes were impaired, we here assume that both central and peripheral processes are affected by progressive alcohol intake. Abstinent alcoholics also have more difficulties to adapt their motor responses to changing task conditions.
BOTH AUTOPSY AND neuroimaging studies of alcohol-dependent patients illustrate that chronic alcohol abuse is associated with structural and functional abnormalities in brain areas that organize and coordinate motor functioning (e.g., vermis, frontal lobes, striatal, and forebrain nuclei) (Baker et al., 1999; Harper and Corbett, 1990; Kril et al., 1997; Moselhy et al., 2001; Pfefferbaum et al., 1997; Sullivan, 2003; Sullivan et al., 1995, 2005). These abnormalities often result in mild to severe deficits in motor functioning that handicap or even endanger alcohol-dependent patients (e.g., alcoholic cerebellar degeneration (ACD), accidents, and injuries) (Charalambous, 2002; Johnson-Greene et al., 1997; Sullivan et al., 1995). A frequently replicated finding for instance is that many alcohol-dependent patients show disturbances of gait and posture (e.g., Ahmad et al., 2002; Sullivan et al., 1995, 2002; Wöber et al., 1998). Research data indicate that 10 to 40% of alcohol-dependent patients have signs of ACD and show broad-based staggering gait and truncal instability (e.g., Johnson-Greene et al., 1997; Yokota et al., 2006). These deficits in gait and posture seem to persist in times of withdrawal and abstinence (e.g., Ledin and Odkvist, 1991; Sullivan et al., 2002, 2005; Wöber et al., 1999).
The existing research data on the execution of small coordinated upper limb movements (e.g., pen movements) in abstinent alcohol-dependent patients are less clear: some researchers concluded that abstinent alcoholics perform worse on these complex motor tasks than healthy controls (e.g., Fama et al., 2007; Parks et al., 2003; Sullivan et al., 2002; York and Biederman, 1988, 1991) whereas other researchers argued that abstinent alcoholics and healthy controls perform equally well on these complex motor tasks (Sullivan et al., 2000, 2002; Tivis et al., 1995). Sullivan et al. (2002) examined the different components of motor functioning (upper limb ataxia, time-linked tapping, sinusoid tracing, timed responses) in abstinent alcoholics and healthy controls. Their main finding was that abstinent alcoholics are slower but more accurate than healthy controls (altered speed or accuracy trade-off). York and Biederman (1988, 1991—Fitts' Task) and Parks et al. (2003—self-paced finger tapping)) also found that abstinent alcoholics are slower than healthy controls. Their research data however illustrated that abstinent alcoholics are less efficient than healthy controls. The data thus indicate that abstinent alcoholics and healthy controls perform differently on upper limb motor tasks. The data of Sullivan et al. (2002—timed tapping, sinusoid tracing) and Tivis et al. (1995—grooved pegboard) on the other hand illustrated that abstinent alcoholics and healthy controls do not differ in psychomotor functioning.
The most straightforward hypothesis to explain this discrepancy in research data on upper limb complex motor tasks seems to be that the research data are found via diverse research instruments that possibly comprise different psychometric properties (e.g., differences in test sensitivity) and capture different aspects of cognitive and motor processes. The tasks that led to differences in speed and/or accuracy (e.g., Fitts' Task, timed responses) almost solely relate to motor processes, while the tasks that did not lead to differences in motor functioning (e.g., timed tapping task, grooved pegboard) relate to cognitive and motor processes. Most researchers that studied fine motor functioning unfortunately ignored the fact that timed responses hold different components such as stimulus evaluation, response selection, response organization, and motor response (Parks et al., 2003; Tivis et al., 1995; York and Biederman, 1988, 1991). These researchers therefore were unable to decide which aspects of information processing are impaired in abstinent alcoholics (Porjesz and Begleiter, 1993; Simmons et al., 2002). Sullivan et al. (2000) were the first to look for differences in reaction (cognitive component timed responses) and movement time (MT) (motor component timed responses). They found that abstinent alcoholics are impaired on MT but not on reaction time (RT), and thought that these deficits in MT were symptomatic of cerebellar dysfunction.
We propose that differences in research instruments, representing differences in cognitive and motor processes, can explain some of the inconsistencies on upper limb complex motor functioning. We thus chose a task that captures a maximum of motor processes and a minimum of cognitive processes, in this case the Fitts' task. Our first hypothesis is that abstinent alcoholics will perform worse on this task than healthy controls. The chosen Fitts' task furthermore allows for variations in motor complexity, in this case the use of large (easy task condition) and small (difficult task condition) targets. As this specific variation in motor complexity almost solely taps into the motor component of timed responses, which seems to be most impaired in abstinent alcoholics (Sullivan et al., 2002), we secondly hypothesise that the differences in MT between abstinent alcoholics and healthy controls will be larger in the small target condition than in the large target condition.

Methods

Sample
Fifty-two abstinent alcoholics, recruited from an inpatient treatment unit, participated in this study (see Dom et al., 2006a,b). During a period of 18 months (2003 to 2004) every second patient admitted to the treatment unit was asked to participate in the study. Eligible patients did not have current or lifetime drug-use disorders. They were free of psychotic, amnesic (e.g., Korsakoff's syndrome), neurologic (e.g., ACD) and/or severe somatic disorders (e.g., AIDS). These patients furthermore followed treatment for at least 3 weeks so that their abstinence could be daily monitored (n = 81). Eleven patients refused to participate. Eighteen patients did not successfully end their treatment program so that they could not be tested. Patients' diagnoses of alcohol and drug-use disorders were based upon DSM-IV criteria (APA, 1994). All diagnoses were made by a psychiatrist (clinical psychiatric interview) and a psychologist (European Version of the Addiction Severity Index (EuropASI)—Hendriks et al., 1989). If available, collateral information was used to confirm the diagnosis.
The participating alcohol-dependent patients were at least 3 weeks abstinent before testing (mean abstinence: 39 days). Abstinence was monitored by regular, randomized tests (breathalyzer tests for alcohol-urine tests for drugs). Almost half of the abstinent alcoholics (49%) took medication including antidepressants (47%), antipsychotics (8%), and mood-stabilizing anticonvulsants (4%). None of the participants took anti-alcohol drugs (e.g., disulfiram, acamprosate).
Control subjects were found through an advertisement in the local newspapers. Respondents were eligible for participation if there was no history of substance use or other (neuro)psychiatric disorders. Respondents were screened for psychiatric symptom severity using the Symptom CheckList (SCL-90; Derogatis et al., 1973), for alcohol-use disorders using the CAGE questionnaire (Cut-Down, Annoyed, Guilt, Eye-opener; Ewing, 1984), and for drug-use disorders using the DAST-10 (Short Drug Abuse Screening Test; Skinner, 1982; Carey et al., 2003). A positive screen was followed by a structured diagnostic interview to exclude current or lifetime psychiatric or substance use disorders. At the end, 52 healthy controls were included in our unmatched, nonalcoholic group. Sample characteristics are given in Table 1.
All participants gave written informed consent. The study was approved by the medical ethics committee of the Brothers of Charity, Psychiatric hospitals, Belgium.
Procedure
To prevent confounding effects of chronic intoxication or acute withdrawal, patients were tested after complete detoxification (minimum period of controlled abstinence: 3 weeks).
Psychomotor Functioning. Psychomotor functioning (timed response-reaction/MT) was measured by means of a Fitts' Task variant. Participants that perform a Fitts' Task move a stylus over a certain distance to a target goal. The distances and target goals usually vary in size.
All participants performed the Fitts' Task in a quiet room on a standard personal computer running OASIS, a specialised movement registration program (De Jong et al., 1996). Stimuli were presented on a VGA computer screen, placed on a table in front of the participants. Responses or pen strokes were registered by means of a professional WACOM Ultrapad A3e graphical tablet (Kiko Software, KH Doetinchem, The Netherlands).
The task configuration consisted of 7 identical circles. The central circle was located in the middle of the screen while the peripheral circles were located at identical distances from the central circle to constitute a virtual regular hexagon (diameter hexagon: 9 cm). The distance to the target circle thus did not vary in size. Circles were either large (Ø 12 mm—block 1 and 4) or small (Ø 6 mm—block 2 and 3). The yellow cursor on the screen showed the stylus location on the graphical tablet. All pen movements on the tablet resulted in congruent cursor movements on the screen (1:1 ratio).
During the task, participants were asked to move the cursor as fast as possible to the circle that highlighted dark blue (target circle). This target circle was always located right next to the starting position. Hence all peripheral circles were possible target circles when the central circle was the starting circle (n = 6) and only 2 adjacent peripheral circles and the central circle were possible target circles when a peripheral circle was the starting circle (n = 3). Participants moved the cursor by moving the stylus over the graphical tablet. They were not allowed to lift the stylus. The response criterion was reached when the cursor stayed for at least 200 ms in the target circle. A subsequent sound of 200 ms signalled the end of the previous trial and the beginning of the next trial. After each series of trials (block) was a short pause. The Fitts' Task consisted of 4 blocks with 3 exercise and 24 test trials in each block. The same sequence of blocks and trials was presented to all subjects.
Task Analysis. Exercise and invalid trials were not analyzed. A low number of trials were considered to be invalid because participants lifted the stylus so that trial analysis became impossible. The RT is the time in which the subject prepared the response, while the MT is the time in which the subject carried out the actual response. The RT started when the target circle highlighted dark blue (stimulus onset) and ended when the subject started to carry out the actual response. The beginning of the actual response was defined as any movements outside the starting circle or as any vigorous movements (>5 cm/s). The MT started at the beginning of the actual response and ended when the subject reached the target circle.
Instruments for Sample Description. The Wechsler Adult Intelligence Scale (WAIS-III; Wechsler, 2000) was used to measure the full scale (FIQ), verbal (VIQ) and performance (PIQ) intelligence quotient. The Dutch version of the Beck Depression Inventory (BDI; Beck et al., 1961; Bouman et al., 1985) was used to look for depressive symptoms. The psychometric variables of this self-report questionnaire are satisfactory (Bosscher et al., 1986). These measures were not given to healthy controls.
Statistical Analysis
The Student t-tests for independent groups were used to compare abstinent alcoholics and healthy controls on continuous variables. Chi-square test tests were used to compare both groups on dichotomous variables. General Linear Model (GLM) procedures were used with Target size (large-small) and Practice (first block-second block) as within-subjects factors, and Group (abstinent alcoholics-healthy controls) as between-subjects factor. To control for confounding variables, we used age as covariate and gender and nicotine dependence as additional between-subjects factors. All data were analyzed using the Statistical Package for the Social Sciences (SPSS-14; SPSS Belux, Brussels, Belgium).

Results

Demographic Variables
Abstinent alcohol-dependent patients were older and more frequently nicotine dependent than healthy controls. There were no significant differences between both groups as to gender and years of education. There were also no significant correlations between any of the behavioral measures and the BDI scores in alcohol-dependent patients. All demographic data can be found in Table 1.
Psychomotor Variables: Fitts' Task
A repeated measures ANOVA with Target size (large-small) and Practice (first block-second block) as within-subjects factors, and Group (abstinent alcoholics-healthy controls) and Gender (male-female) as between subjects factors, and Age as covariate were used to evaluate the differences in RT and MT between abstinent alcohol-dependent patients and healthy controls, and to evaluate the effect of a change in Target size on RT and MT.
The repeated measures ANOVA showed a significant Group effect on RT [F(1,97) = 9.998; p < 0.005] showing longer RTs in abstinent alcoholics than in healthy controls (see Table 2). The Target size effect [F(1,97) = 2.721; ns] did not reach significance. The Group × Target size effect [F(1,97) = 4.615, p < 0.050] on the other hand was significant. This means that Target size on itself did not influence RT, but that abstinent alcohol-dependent patients needed proportionally more time to prepare a response aimed at a small target than to prepare a response aimed at a large target (see Fig. 1). Younger participants had faster RTs than older participants [F(1,97) = 9.020; p < 0.005]. There was no gender difference [F(1,97) = 2.006; ns].
The repeated measures ANOVA revealed a significant Group effect [F(1,97) = 10.463, p < 0.005] on MT. This finding shows that abstinent alcohol-dependent patients have slower MTs than healthy controls (see Table 2). The effects of Target size [F(1,97) = 68.605, p = 0.000] and Group × Target size [F(1,97) = 13.405, p = 0.000] proved to be significant. We therefore conclude that participants needed more time to reach a small target than to reach a large target and that abstinent alcoholics were more impaired by task difficulty than healthy controls. Age [F(1,97) = 7.188; p < 0.010] and gender [F(1,97) = 6.760; p < 0.050] did affect MT. Older and female participants had significantly longer MTs than their younger and male counterparts. The additional controls for age, gender, and nicotine dependence did not change the significance of the aforementioned findings.

Discussion

The aforementioned data showed that (i) cognitive and motor aspects of motor functioning are both impaired in abstinent alcoholics and (ii) that abstinent alcoholics are proportionally more influenced by task difficulty than healthy controls.
The research results showed that abstinent alcoholics need more time to perform simple motor acts than healthy controls. These data resemble the data from York and Biederman (1988, 1991) and Sullivan et al. (2002). In agreement with these authors, we concluded that impairments in motor functioning are an important finding within abstinent alcoholics. Contrary to Sullivan et al. (2002) who found that the observed psychomotor slowing was solely defined by motor processes, we found that the observed psychomotor slowing results from both impaired cognitive (RT) and motor processes (MT). The different interpretations of the existing research results perhaps relate to differences in measurement procedure and/or errors. Sullivan et al. (2002) for instance asked participants to press the "home button" (starting point) until they heard a sound signal that preceded the illumination of the "test button" (target point). This means that participants could lift the index finger (end RT-start MT), think about the direction of the response, select the response and move the index finger to the target (end MT). This possibly implied that MT held all motor processes and some cognitive processes. We, on the other hand, used a procedure in which RT held all cognitive processes and some motor processes. As mentioned before, MT started when participants made movements outside the starting circle or when they made vigorous movements (>5 cm/s). This possibly implied that some participants already moved very slowly (<5 cm/s) towards the target circle when they were still in the starting circle. The differences in research results thus can be attributed to differences in measurement procedures and/or errors. The further fine-tuning of these research methods possibly helps to resolve this research issue. The idea that cognitive processes are impaired in abstinent alcoholics however is not new (Oscar-Berman and Marinkovic, 2003; Sullivan et al., 2000). Several researchers that used behavioral tasks that solely measure cognitive processes found that abstinent alcoholics give slower responses than healthy controls (e.g., Bertera and Parsons, 1973; Cohen et al., 1997; Talland, 1963; Vivian et al., 1973). The idea that both cognitive and motor processes might be influenced in motor functioning implies that both central and peripheral processes are influenced after progressive alcohol intake.
The present research data also indicated that abstinent alcoholics and healthy controls were differentially influenced by task difficulty. The research data showed that abstinent alcoholics needed proportionally more time than healthy controls to reach small targets (difficult task condition) than to reach larg targets (easy task condition). The research data further showed that cognitive and motor processes were both more impaired in abstinent alcoholics than in healthy controls in the small target condition than in the large target condition. We believed that the small differences in RT need to be seen as measurement errors. We presumed that participants that move quite slowly to a target goal (MT small target condition) will need more time to achieve a velocity that is higher than 5 cm per second than participants that move quite quickly to a target goal (MT large target condition). These data thus show that abstinent alcoholics have more difficulties in motor processing when task conditions become more difficult than healthy controls. Motor processing involves movement programming and initiation, agonist and antagonist muscle groups' coordination, response execution (= motor act), and feedback monitoring (Sabbe et al., 2001). Disorders in motor performance particularly in smooth and timed movements have been associated with cerebellar damage (Gilman, 1994). Thus, the above mentioned findings possibly reveal cerebellar dysfunctions or disruptions in the frontocerebellar circuitry. This idea has already been suggested by Sullivan (2003) and Sullivan et al. (2003).
Impairments in motor functioning have important clinical and social implications. An important feature of the Fitts' task is that it implies visually guided motor responses that are critical to a broad variety of everyday operations (e.g., motor vehicle operation, motor skills at work or at home). Liguouri et al. (1999) stated that the effects of alcohol on driving capacities were to be measured in a direct way (e.g., actual or simulated driving). They felt that indirect measures (e.g., psychomotor tasks that require important driving skills such as visual discrimination and motor reaction) are often too insensitive to measure impairments in driving capacities. We here demonstrated that abstinent alcohol-dependent patients are impaired on measures of psychomotor speed (slowing in MTs). We thus can assume that abstinent alcohol-dependent patients will find it more difficult to drive a vehicle than healthy controls.
Several limitations of the current investigation need to be discussed. First, this research was performed within a naturalistic sample of abstinent alcoholics following inpatient treatment (treatment as usual). As a result, a considerable number of patients (=49%) used psychiatric medication at the time of testing. This finding possibly biased the results on RTs and MTs. The analysis, in which we compared differences in timed response in abstinent alcoholics that did not take medications and healthy controls, however did not lead to different research results. Therefore, we here conclude that psychiatric medication intake did not significantly influence the above mentioned results. Second, there was no perfect age or gender match between abstinent alcoholics and healthy controls. Considering the fact that both variables are known to bias motor performance, we recommend a careful interpretation of these results. Correcting for these and other variables (current nicotine dependence) however did not change our results.

Conclusion

The results of the present investigation indicated that recently abstinent alcoholics are impaired on a behavioral level. Abstinent alcoholics are significantly slower than healthy controls in performing the Fitts' task. The slowing in total time reflected both a slowing in RT and in MT. Abstinent alcoholics further found it disproportionally more difficult to answer to increased task difficulties than healthy controls.

Acknowledgment

This study was funded by an internal grant of the Brothers of Charity, Belgium.

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York JL, Biederman I (1991) Hand movement speed and accuracy in detoxified alcoholics. Alcohol Clin Exp Res 15:982-990.
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