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LATERALITY, 2006, 12 (1), 50 63

Turning bias and lateral dominance in a sample of able-bodied and amputee participants
M. J. D. Taylor and S. C. Strike
Roehampton University, London, UK

P. Dabnichki
Queen Mary, University of London, UK
Turning bias is the tendency to turn towards a given direction. Conflicting results from previous studies suggest that a number of factors may influence turning direction. The aim of this study was to determine if biomechanical asymmetries influence turning bias. A total of 100 able-bodied participants, and 30 trans-tibial amputees who, by definition, possess a functional asymmetry, volunteered to participate in the study. The right hand and right foot were significantly dominant for the able-bodied sample. Able-bodied participants showed a significant turning preference towards the left, which was opposite to the dominant hand and foot. The amputees were significantly right-hand dominant and the side of the amputation influenced foot dominance. The amputee sample showed no preferred turning direction. Turning bias indices in the amputee sample were not significantly associated with handedness, footedness, side of amputation, or dominance prior to amputation. The lack of a preferred direction of turn in the amputee sample suggests that biomechanical asymmetries can influence turning bias.

Humans possess a functional asymmetry of the hands, feet, eyes, and ears. Approximately 80 90% of humans are right-handed, 60 80% are rightfooted, and 80% of participants have a dominant hand and foot on the same side (Coren, 1992). Certain gait asymmetries have been suggested as being linked to lateral dominance. For example, during walking, right-footed participants utilise the right limb to propel the body and the left limb to stabilise (Sadeghi, Allard, & Duhaime, 1997). The way in which balance is controlled during unipedal stance has also been suggested as being
Address correspondence to: Mr M. J. D. Taylor, School of Human and Life Sciences, Roehampton University, Whitelands College, Holybourne Avenue, London, UK. E-mail: matt@mjdt.freeserve.co.uk We would like to thank John Ross at Chas. A. Blatchfords and Sons for the access to amputee patients at Kings Healthcare Centre, Crystal Palace, London, UK. We would also like to thank the reviewers for their helpful comments. # 2006 Psychology Press, an imprint of the Taylor & Francis Group, an informa business http://www.psypress.com/laterality DOI: 10.1080/13576500600892745

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dependent on limb dominance. Recent work (Golmer & Mbongo, 2004) has reported, regardless of visual conditions, that left-footed participants displace the centre of pressure towards the outside of the supporting foot, whereas right-side-dominant participants displaced it towards the right side, regardless of whether the right or left foot was supporting. This led Golmer and Mbongo (2004) to conclude that postural control was regulated differently for the left-footed participants (through perception of the centre of body mass) compared to the right-footed participants (asymmetrical utilisation of head receptors). Different potential intrinsic and extrinsic factors could influence turn direction. Suggested intrinsic factors are visuospatial functioning (Gordon, Busdiecker, & Bracha, 1992; Mohr, Landis, Bracha, Brugger, & ViaudDelmon, 2004), fluctuation of ovarian hormones during the menstrual cycle (Mead & Hampson, 1997), asymmetry in the basal ganglia dopaminergic function (Bracha, Shults, Glick, & Kleinman, 1987b), and vestibular asymmetries (Previc & Saucedo, 1992). Extrinsic factors such as foot placement have also been shown to affect preferred turning direction (Lenoir, Van Overschekde, De Rycke, & Musch, 2006). For example, participants turn towards the direction opposite to the foot placed in front. According to the whole body observational method (Yazgan, Leckman, & Wexler, 1996) right-handed participants were significantly more likely to turn left. This suggests that the majority of right-handed amputees should also turn left. However unilateral amputees have a significant asymmetry * an asymmetry that may also have caused foot dominance to be altered. Such an asymmetry may affect turning bias and, as such, suggests that turning bias may also be influenced by biomechanical/anthropometrical asymmetries. Thus the aim of this study was to assess if lateral dominance changes following amputation, and the effect a biomechanical asymmetry has on turning bias.

METHOD AND MATERIALS


The test protocol for this study was reviewed and approved by the ethics committee at Roehampton University. All participants gave informed consent.

Sample
Participants in the able-bodied and amputee samples were free from any head trauma causing dizzy spells/loss of consciousness and from any major neurological illness. A total of 100 healthy able-bodied participants (47 male, 53 female, mean age 23.8, SD / 8.2 years) volunteered for participation in

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the study; 30 trans-tibial amputees, (22 males, eight females, amputation was on the right side for 60% of participants), patients of Kings Healthcare Centre, London, aged M / 54.5, SD / 14.2 years, volunteered for the study. Time since amputation ranged from 1 to 54 years (M / 15.7, SD / 16.1 years) and all walked unaided, i.e., without a stick or crutches. The requirement to walk unaided reduced the mean age and relative number of vascular amputations compared to the UK national amputee statistical database (NASD, 2004) figures. This suggests that the sample used in this present study was not representative of the whole population.

Procedure
The whole-body measure of assessing turning bias (Yazgan et al., 1996) required each participant to walk from a mark towards a mark 12 metres away (room dimensions /15 /8 m), stop with feet approximately shoulderwidth apart, turn around and walk back towards the mark at the other end, and repeat the procedure, resulting in 10 turning events (for the amputees this was as many times as comfortable). A written record of the direction of turn was made in addition to a digital video (JVC) recording. The spatial environment was controlled in such a way as to prevent external factors influencing turning bias. Participants were told that their gait was being analysed. If they asked which way to turn it was strongly suggested that this was not important and that they should do it in the most comfortable way. The tester and the video camera were deliberately placed at opposite ends of the line of progression in order to counter each others presence. The testing space was symmetrical * one side of the room was identical to the other. No lateral illumination in the form of either windows or artificial lights was present, to avoid influencing the selection process of the turning direction. The room was closed to external sound sources. There were no other ongoing activities in the space.

Turning bias index


Turning bias was scored according to a turning bias index, which was a percentage of left turns (number of left turns/total number of turns, multiplied by 100). A level of 60% was set as the cut-off for left bias, and this was in agreement with Yazgan et al. (1996). Indices between 60% and 100% indicated a left bias, between 0% and 40% indicated a right bias, and 41 59% no bias. The criterion was used for both amputee and ablebodied samples.

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Lateral dominance tests (post-test questionnaire)


In the present study the Waterloo Footedness Questionnaire Revised (WFQ-R) (Elias, Bryden, & Bulman-Fleming, 1998) was used to evaluate footedness in both the amputee and able-bodied sample. This is one of the most comprehensive footedness questionnaires. It offers a wide range of questions, which encompass unilateral and bilateral tasks, and therefore allows an accurate assessment and offsets possible bias in the answers. However, this questionnaire (Elias et al., 1998) was specifically designed for able-bodied participants and certain parts of it are not appropriate for amputees. That is why the questionnaire was modified for the participating amputees. For the amputee sample, question 7 (If you wanted to pick up a pebble with your toes, which foot would you use? ) was omitted. Questions 11 (Is there any reason why you have changed your foot preference? ) was reworded to: Following amputation have you noticed/can you remember changing your foot preference? Question 12 (Have you ever been given special training or encouragement to use a particular foot for certain activities? ) was also re-worded to: Other than gait training, have you been given any special encouragement to use a particular foot for certain activities? Handedness of all participants was assessed using the Lateral Preference Inventory (Coren, 1993), which consists of four handedness measures.

Data analysis
The WFQ-R consisted of 10 questions scored on a 5-point Likert scale (scaled left to right, /2, /1, 0, 1, 2). The Edinburgh handedness inventory was scored similarly (/1, 0, 1). A negative questionnaire score indicated leftfootedness/handedness, and a positive score right-footedness/handedness. A score of zero indicated equal preference. The statistical analyses used were in agreement with earlier turning bias studies (Bracha, Seitz, Otemaa, & Glick, 1987a; Lenoir et al., 2006; Mead & Hampson, 1996; Yazgan et al., 1996). To test if a significant bias in turning was present in both samples, a one-sample t -test against a value of 50% was performed on the turning bias scores for each group. A chi-squared (x2) test was used for exploring the differences in frequency in each category (handedness, footedness, and side of amputation). A binomial test was used when comparing two proportions with small N . An ANOVA with a post-hoc Scheffe test was calculated to account for possible gender differences between handedness, footedness, and turning bias scores in both the able-bodied and amputee samples. A Pearsons correlation coefficient (r ) was calculated between scores on the handedness and footedness inventories and turning bias for the able-bodied and amputee samples. Significance was set at p B/.05 and all tests were two-tailed.

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RESULTS
Right-side dominance (Table 1) was significantly prevalent for the ablebodied sample: 92% of participants were right-handed, 89% were rightfooted, and 91% were both right-handed and right-footed. The scores of the footedness and handedness inventories correlated significantly with each other, r (98) / .465, p B/.001. For the amputee sample, handedness was significantly right sided, there was no significant preference for footedness (Table 1), and no significant correlation between hand and foot dominance scores (r values B/.2). Footedness scores were significantly different for the amputee sample compared to the able-bodied sample, F (1, 128) / 12.15, MSE / 20.00, p B/.001. There was no significant difference between genders for footedness and handedness inventories. As a group, the intact limb was the preferred limb for 19 of the amputees (binomial test, p / .200). The intact limb (right) was the dominant limb for the majority of participants with a left amputation (n / 10, binomial test, p / .002). The preferred lower limb for those participants with a right amputation (N /18) was more varied with 44%, x2 (2, n /8) / 1.33, p / .513, choosing the intact limb, 33% equal preference, and 22% choosing the amputated limb. Right-side dominance (hand and foot) was only prevalent in 40% of the sample, compared to 91% for the able-bodied sample, suggesting that 50% of amputees altered foot dominance following amputation. Retrospectively, 21 amputees could recall which foot was used for each task prior to amputation. Of these respondents 14 (65%) reported that prior to amputation they were right-foot dominant, and 13 reported altering footedness following amputation. Of those participants who reported altered footedness, eight were right-sided amputations. With regards to question 12, amputee participants reported receiving advice for going up steps with the good (intact) limb and stepping down with the bad (amputated) limb. Past literature has reported a link between handedness and turning preference (Yazgan et al., 1996). Because too few left- or equal-dominanthanded participants were tested in this study, a separate analysis of left- and right-handedness could not be carried out. Therefore only right-handed participants are reported in the following section (able-bodied sample N / 92, males N / 43, females N / 49; amputee sample N / 27, male N / 20, female N / 7, right side amputation N / 16, left side amputation N /11). The able-bodied sample tended towards a left-preferential turn with a turning bias index of 66.8%. This was significantly different from 50% (Table 2). A leftward bias was also significantly more prevalent than either right or non-bias, x2(2, N /60) / 48.60, p B/.001. Participants who were

AMPUTEE LATERAL DOMINANCE AND TURNING BIAS

TABLE 1 Handedness and footedness frequencies in both samples


Able-bodied sample N / 100 Amputee sample N / 30 Intact (binomial test) n /19, p / .200

Right Handedness Footedness x2(1, n /92) / 70.56, p / .0001 x (1, n /89) / 60.84, p / .0001
2

Left n /8 n /11

Ambi-sided

Right x2(1, n /27) / 11.63, p / .001 x (2, n /14) / 2.21, p / .321


2

Left n /3 n /9

Ambi-sided n /7

55

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TABLE 2 Turning bias indexes (mean and SD), right-handed participants only, for each sample
Turning bias index (%) Able-bodied sample Amputee sample Amputee dominance change Amputee no-dominance change 66.8 47.4 43.6 35.5 (38.8) (43.1) (43.9) (39.5) One-sample t-test (test value / 50%) t (92) / 4.15, p B/ .001 t (27) / /0.29, p / .77 t (10) / /0.31, p / .75 t (8) / /1.03, p / .33

Dominance change indicates change in foot dominance reported by amputees before and after amputation.

right-handed and right-footed (N /84) had a significant turning preference to the left: x2(2, N /57) / 49.07, p B/001. Turning bias indices were towards the left and significantly different from 50% for both genders * male turning bias index / 66.9%, t (43) / 2.91, p B/ .01; female turning bias index / 66.7%, t (48) / 2.93, p B/.01 * indicating an overall left bias. A left bias was also significantly more frequent for both genders: male, x2(1, N /29) / 48.60, p B/.001; female x2(1, N /31) / 20.85, p B/.001. Females were also significantly more likely to turn towards the same direction 100% of the time, X2(1, N /34) / 7.36, p B/.01, than were males, X2(1, N /22) / .023, p / .879. The ANOVA revealed there was no significant difference between genders for handedness and footedness scores obtained from the inventories and turning bias indices for the able-bodied sample. However, a significantly greater number of female participants, x2 (1, N /34) / 7.36, p B/.05, turned in the same direction 100% of the time. From feet together, the turn was completed in two steps (Figure 1a). Individually, all amputees reported a turning preference: as a group the amputees showed no bias for turning (turning bias index / 47.4%). A onesample t -test revealed no significant difference from 50% (Table 2), indicating that amputees as a sample did not possess a preferred directional bias. There was no significant difference between turning bias scores and gender. Of the amputees, 59% preferred to turn towards the same side as their amputation, however this was not significant. Turning bias was also not significantly associated with footedness or handedness (Table 3). A trend of turning towards the amputated side was also noted when separating the amputees into side of amputation, with 10/16 (binomial test, p / .549) right-side amputees and 7/11 (binomial test, p / .454) left-side amputees preferring to turn to the amputated side. A similar trend was also noted with those amputees who reported the intact limb as the dominant limb (n /16) with nine preferring to turn towards the amputated side.

A 3 2

B 3 5 4 4 5 1 2

3 2
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4 7 6 1

5 1

Figure 1(A). Approximate foot placements when turning through 1808 towards the left for the able-bodied sample. Grey feet indicate the right limb and solid black feet indicate the left limb. The dashed and solid arrows represent the direction of travel and swing phases respectively. (1) Approach towards the turning area. (2) Right and left feet together. (3) Left limb swung behind into new direction while right limb provides support. (4) Right limb swung around into new direction while left limb provides support. (5) Continuation of straight gait back towards the opposite turning area. A similar pattern was seen for turns towards the right. Figure 1(B). Approximate foot placements when turning through 1808 towards the amputated side for the amputee sample. Solid black feet indicate the amputated limb and grey feet indicate the intact limb. (1). Approach towards turning area. (2) Intact limb and amputated limb together. (3) A small extra step forward taken by the intact limb prior to turning. For some participants more steps were taken at this stage, i.e., shufing around. (4) The amputated limb swings back towards the original direction and takes up stance facilitated by the intact limb taking weight. (5) Intact limb swung from position 3 and takes up stance. (6) Amputated limb swung from 4 back into the original line of progression. (7) Intact limb swung from 5, continuation of straight gait back towards the opposite turning area. A similar strategy was used when turning to the right. Figure 1(C). Approximate foot placements when turning through 1808 towards the intact side for the amputee sample. (1). Last approach step. (2) Intact limb and amputated limb together. (3) Amputated limb swung around the outside of the intact limb and takes up stance. (4) During the amputated limbs stance phase, the intact limb was lifted, swung, and realigned back along the original direction. (5) Amputated limb swung back towards original direction, and continuation of straight gait back towards the opposite turning area. A similar strategy was used when turning to the right. Note: extra steps (Figures 1B and 1C) were taken by some amputees between positions 3 and 4. For ease of presentation these are not shown.

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TAYLOR ET AL. TABLE 3 Lateral dominance and turning bias for the right-handed amputee sample
Turning towards Dominant hand Dominant foot Amputated side Entire sample n /27 Binomial statistics n /11/27, p / .442 n /13/27, p / 1.00 n /16/27, p / .442

Table 2 presents the turning bias scores for the 18 right-handed amputees who could remember which foot was dominant prior to amputation. The amputees who did not alter foot dominance presented a tendency towards a more rightward turning bias compared to those that did alter dominance. However, a one-sample t -test revealed no significant difference from 50% (Table 2) for either the foot-dominant change or no-footdominant change sample. An ANOVA revealed no significant difference between dominance change, no dominance change, and the whole amputee sample for turning bias indices. However, the turning bias index for the amputee sample differed significantly from the able-bodied sample, F (3, 128) / 3.07, MSE / 1592.7, p B/.05. Generally, an extra step or steps were taken prior to turning compared to able-bodied participants. When turning to the amputated side the amputees took one step more on average than when turning toward the amputated limb (Figures 1b & 1c).

DISCUSSION
The left bias for the able-bodied sample agrees with those studies using the same method (Glover, Powers, Bergman, Smits, Telch, & Stuber, 2003; Yazgan et al., 1996; Yazgan, Peterson, Wexler, & Leckman, 1995) and recent rotometer studies (Mohr & Bracha, 2004; Mohr, Landis, Bracha, & Brugger, 2003). No significant difference in turning bias indices between the sexes was found in this study. However, females were significantly more likely than males to turn towards the same direction 100% of the time. This adds support to Bracha et al. (1987a), who stated that females were more lateralised than males for turning behaviour. Right-handed and right-footed participants in the able-bodied sample preferred to turn to the left. Footedness appears to have had an influence on turning bias * turns were generally away from the dominant foot. However, because 91% of all righthanded participants were also right-footed, handedness and footedness cannot be independently assessed. The combination of footedness and turning bias has received relatively little attention in the literature.

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A recent re-analysis of Bracha et al. (1987a) has also revealed a left-turning preference for right-footed participants (Mohr & Bracha, 2004). The results were non-significant, due to the small number of non-right-footed participants in their sample. Further work is required to understand the role of footedness and turning bias, because footedness has been shown to point to cerebral asymmetries (Elias et al., 1998). From the able-bodied sample it could be assumed that right-handed amputees would also turn left if biomechanical asymmetries were not influential. However, for the amputee sample there was no significant preference towards turning away from the dominant hand or foot. This is likely due to their unusual pattern of footedness. Only 47% reported a right foot dominance, 23% illustrated ambi-sidedness, and 30% illustrated a left foot dominance. The pattern of footedness was to be expected since a number of amputees reported that their dominant limb was on the same side as their intact limb. However, turning bias was also not significantly associated with the side of amputation, with 59% of amputees preferring to turn towards their prosthetic side. An exploration of this trend is warranted in further work by studying a sample of amputees with the sameside amputation. The results from the amputee sample suggest that the biomechanics of the turn were affected (indicated by the increased number of steps taken to complete the turn), and that the participant biomechanics influenced turning bias. Only recently has biomechanics been suggested as an influential factor for turning bias (Lenoir et al., 2006). This was accomplished by manipulation of the turning bias method, by altering foot placement position (Lenoir et al., 2006). This present study kept foot placement constant prior to the turn, therefore suggesting that anthropometrical asymmetries, which lead to biomechanical asymmetries, also influenced turning bias. The biomechanical and anthropometrical asymmetries associated with unilateral amputation must have been contributing factors to turning preference, otherwise turning bias indices would have been comparable to the able-bodied sample. Arguably, the loss of a limb is a significant factor influencing turn direction. This is because the amputation results in reduced coordination and proprioceptive functioning. With the loss of the ankle, amputees are unable to employ an ankle strategy to control posture, as it requires sequential activation of the posterior muscles, including the gastrocnemius. The biomechanics of turning gait may influence the turning direction. For example, for the able-bodied sample a significant majority turned away from the dominant foot. With the dominant foot (right) rooted to the ground, acting as a stabiliser, the non-dominant (left) leg was mobilised into the new direction. Its role as a stabiliser was arguably more important

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than as a mobiliser. With the dominant limb established as the stabilising foot, the choice was now to turn towards or away from that limb. The reason why a turn away from the dominant limb was used is seen in the turning-gait literature and is related to the complexity of the task. Turning away from the stance limb (step turn) ensures balance is maintained by keeping the centre of mass (CM) between both limbs. However, when turning towards the stance limb (pivot/crossover turn), the CM displaces outside the base of support, threatening balance (Taylor, Dabnichki, & Strike, 2005). This pattern of turning away from the dominant stance limb is similar to the manipulated turning conditions enforced by Lenoir et al. (2006), where a turn is away from the most forward positioned foot. This may also explain why the T-maze method (Scharine & McBeath, 2002) reported a right bias because foot placement was not controlled. For the amputee sample a trend of turning towards the prosthetic side was noted, allowing the intact limb to act as stabiliser during the initiation of the turn. Because of the loss of the ankle, possible adaptations are made to those tasks that demand increased postural control by employing the intact limb. An analogy to the amputee sample can be made from hemi-PD patients who also present a biomechanical asymmetry. A consequence of this potential asymmetry is that symptoms of rigidity and tremor occur opposite to the side with the lesion. With regards to turning bias, Bracha et al. (1987b) reported that these patients spontaneously rotate towards the side that is believed to contain the lower levels of dopamine. Thus these patients turned away from the more rigid side. This suggests that the less affected side provided stability, as the more rigid side was mobilised, similar to the amputee sample in this present work, who used the intact limb to provide support. However, to state that biomechanical asymmetries solely influenced the turning bias of the amputee sample is perhaps an oversimplification. If this were a sole contributor then turning bias for this amputee sample would have been an almost constant turn towards or away from the amputated limb, which was not the case. This is because turning bias has also been reported to be opposite to the hemisphere with the most active dopamine system (Bracha et al., 1987b). It has also been suggested that turning bias is influenced by visuospatial functioning (Gordon et al., 1992; Mohr et al., 2004), fluctuation of ovarian hormones during the menstrual cycle (Mead & Hampson, 1997), and vestibular asymmetries (Previc & Saucedo, 1992). Because of this wide range of potential causative factors, preferred turning direction has differed between studies. Mohr et al. (2004) compared three different whole-body movement tasks and suggested that veering was under dopaminergic control, and visual control was crucial for long-term spontaneous turning (rotometer), illustrating that bias can also alter between tasks. Definitive conclusions are further complicated by the numerous methods for collecting

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data. To fully evaluate the influence of methodological approaches to turning bias assessment, the different turning bias methods should be tested on an identical sample. Only then can a firm conclusion be drawn on whether the bias is affected by the complexity of the task (biomechanical) and physiological sensing, and their priority order in the brains control strategy. The causative factors for turning bias, including biomechanics, may take hierarchal priority depending on the sample pathology (i.e., amputees), environmental factors, and available stimuli. For example, the neutral turning bias for the amputee sample suggests that a potential conflict between causative factors may exist, which ultimately decides turning direction. This could be tested by taking a sample of normal participants, immobilising the ankle of the dominant foot and then the non-dominant foot, and comparing turning bias with and without the restriction. A similar approach could be applied to veering, which requires blindfolding participants, thereby also eliminating potential visual influences. Furthermore, the hemi-Parkinsons disease (PD) patients of Bracha et al. (1987b) provide an interesting sample, possessing two significant asymmetries (dopamine activity and biomechanical). Future work may wish to expand on this by testing lateralised measures that are sensitive to dopaminergic modulation along with a biomechanical constraint. The amputee sample used in this present study was varied in its composition. For example, as a sample the amputees were older than the able-bodied sample. Age may potentially influence turning bias due to vestibular impairments (Sloane, Baloh, & Honrubia, 1989) and affect turning mechanics (Thigpen, Light, Creel, & Flynn, 2000) compared to younger participants. A more satisfactory approach may be to test a sample of young, traumatic amputees who all have either right- or left-sided amputations. In doing this, the age of the sample and potential variation between amputees would be reduced.

CONCLUSION
The results have shown that turning bias in a sample of amputees differed significantly from an able-bodied sample. It is possible that biomechanical asymmetries have caused this difference; however past research also suggests that turning bias is affected by numerous other factors that, along with biomechanical asymmetries associated with amputation, may be competing for dominance.
Manuscript received 26 October 2005 Revised manuscript received 4 July 2006 First published online 17 August 2006

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