Brain (2000), 123, 2512–2518
Handedness and hemispheric language dominance
in healthy humans
S. Knecht, B. Dra¨ger, M. Deppe, L. Bobe, H. Lohmann, A. Flo¨el, E.-B. Ringelstein and
H. Henningsen
Department of Neurology, University of Mu¨nster, Germany Correspondence to: Stefan Knecht, MD, Department of
Neurology, University of Mu¨nster, Albert-Schweitzer-Strasse
33, D-48129 Mu¨nster, Germany
E-mail: knecht@uni-muenster.de
Summary
In most people the left hemisphere of the brain is
dominant for language. Because of the increased incidence
of atypical right-hemispheric language in left-handed
neurological patients, a systematic association between
handedness and dominance has long been suspected. To
clarify the relationship between handedness and language
dominance in healthy subjects, we measured lateralization
directly by functional transcranial Doppler sonography
in 326 healthy individuals using a word-generation task.
The incidence of right-hemisphere language dominance
Keywords: language lateralization; hemispheric dominance; handedness; functional Doppler ultrasonography
Abbreviations: ANOVA ϭ analysis of variance; fMRI ϭ functional MRI ; fTCD ϭ functional transcranial Doppler
ultrasonography
Introduction
Language is lateralized to the left hemisphere of the brain
but can occasionally also be found in the right hemisphere
(Knecht et al., 2000). This variability indicates the high
degree of freedom with which the brain can instantiate
language. Factors associated with lateralization inform us
about limitation to this freedom and may also be important
limitations in the recovery from aphasia after stroke by
recruitment of the intact hemisphere. One factor which has
been associated with language dominance is handedness.
Since the description of left-hemisphere language regions
in right-handed patients by Paul Broca in the 19th century,
it has been speculated that the reverse, i.e. right-hemisphere
language dominance, should be true of left-handers. This
claim has been widely accepted as the ‘Broca rule’, although
Broca never explicitly postulated such a rule (Harris, 1993).
Luria was among the ﬁrst to point out that such an association
could not be universally true because even in left-handers
aphasia usually occurs after a lesion to the left hemisphere
(Luria, 1976). Even now, our knowledge about the suspected
association between handedness and language dominance
© Oxford University Press 2000
was found to increase linearly with the degree of lefthandedness,
from 4% in strong right-handers (handedness
⍧ 100) to 15% in ambidextrous individuals and 27% in
strong left-handers (handedness ⍧ –100). The relationship
could be approximated by the formula: likelihood
of right-hemisphere language dominance (%) ⍧ 15% –
handedness (%)/10. These results clearly demonstrate
that the relationship between handedness and language
dominance is not an artefact of cerebral pathology but a
natural phenomenon.
rests almost exclusively on studies of neurological patients.
In this population, however, there is an increased incidence
of pathological left-handedness and right language
dominance, as the control of both dexterity and language
can shift to the right hemisphere after long-standing lefthemisphere
lesions (Rasmussen and Milner, 1977; VarghaKhadem
et al., 1985; Woods et al., 1988; Loring et al.,
1990). Evidence from patients with brain lesions of sudden
onset, such as stroke, provide some indirect evidence about
the status of right-hemisphere language dominance in healthy
subjects. These studies are based on relatively small numbers
of atypical aphasias, as in left-handers with right-hemisphere
stroke. Furthermore, patients who present with language
disturbances after right-sided cerebral infarction have not
infrequently had strokes in the other hemisphere, rendering
conjectures on the original hemisphere of language dominance
unreliable (Pedersen et al., 1995). As a consequence, studies
of the incidence of aphasia after stroke in relation to
handedness have provided widely diverging results. Two
groups reported an increased incidence of language deﬁcits
Handedness and language dominance 2513
Table 1 Rate of right-hemisphere dominance in relation to parental left-handedness
Handedness of subject
–75 or lower Between 75 or higher
(strong left-handers) –76 and 75 (strong right-handers)
ϩ Ϫ ϩ Ϫ ϩ Ϫ
Parental left-handedness
n 14 43 13 88 10 145
Degree of handedness, –100 –100 –60 –10 100 100
median (quartiles) (–100, –90) (–100, –90) (–60, 50) (–52, 42) (100, 100) (89, 100)
Right-hemisphere language 29 23 15 17 10 4
dominance (%)
in left- or non-right-handers after right-hemisphere stroke
(Gloning, 1977; Basso et al., 1990). Another group found no
such increase and suggested a negligible role of the right
hemisphere in speech function in most left-handers who do
not have early left-hemisphere damage (Kimura, 1983).
A new, very efﬁcient perfusion-sensitive technique has
made it possible to clarify the association between handedness
and language dominance in healthy subjects in a
representative and quantitative way. This technique is
functional transcranial Doppler ultrasonography (fTCD), and
is based on the same physiological principles as functional
MRI (fMRI) (Deppe et al., 2000). It has allowed us to
measure the lateralization of language in a validated and
highly reproducible way in a total of 188 healthy subjects
and to control adequate cooperation in every case (Knecht
et al., 1998a, b). We have also employed this technique to
assess the variability of language lateralization with respect
to gender in healthy subjects (Knecht et al., 2000). Like
other researchers in the ﬁeld, we had to conﬁne our study to
moderate and strong right-handers because we lacked
sufﬁcient left handers for a representative analysis (Frost
et al., 1999; Springer et al., 1999). Thus, we had not
been able to evaluate the role of handedness in language
lateralization (as had been suggested by an anonymous
reviewer). For the present study, we recruited more than 100
left-handed healthy subjects in addition to those reported in
the previous study in order to answer the following questions:
(i) can we conﬁrm an association of language lateralization
and handedness in healthy subjects? (ii) Can we quantify
this relationship? (iii) Can we make predictions about the
basis of language lateralization?
Methods
The work was part of the Mu¨nster functional imaging study
on the variability of hemispheric specialization in health and
disease (Deppe et al., 1997, 2000; Knecht et al., 1998a, b,
2000). Healthy volunteers were recruited by newspaper
advertisement. The advertisement was intended to address
especially subjects with non-right-handedness. They were
not offered any ﬁnancial reimbursement. Subjects were
interviewed about the handedness of their parents. Possible
answers were ‘right’, ‘left’ and ‘unknown’. Subjects were
excluded if information from a standardized questionnaire
suggested the possibility of any neurological disorder,
particularly perinatal asphyxia or kernicterus, head trauma,
loss of consciousness, epileptic seizures, meningitis or
encephalitis, or delayed or disturbed language development.
Subjects were also excluded if they had failed to complete
the equivalent of high school (Realschule or Gymnasium).
Additionally, ~3% of subjects had to be excluded because
fTCD could not be performed, due to inadequate sonographic
penetration of the skull. A total of 326 subjects were thus
included in the study: 198 females (age range 15–49 years,
mean 26, SD 5.1) and 128 males (age range 19–46 years,
mean 26, SD 4.6). All subjects gave informed consent to
participation in the study, which was approved by the ethics
committee of the University of Mu¨nster. Handedness was
assessed by the Edinburgh Inventory (Oldﬁeld, 1971), which
ranges from –100 for strong left-handedness to ϩ100 for
strong right-handedness. Individuals were assigned to one of
seven categories of handedness, which are shown in Fig. 3.
Hemispheric language dominance was determined, as in
previous studies, by fTCD using a word generation task
validated by direct comparison with intracarotid amobarbital
injection and fMRI and tested for reproducibility (Knecht
et al., 1996, 1997, 1998a, b; Deppe et al., 1997, 1998).
Details of the procedure are shown in Fig. 1.
Results
The distribution of hemispheric language dominance varied
with the degree of handedness [P Ͻ 0.0001 by analysis of
variance (ANOVA)] (Fig. 2).The more right-handed the
subjects were, the lower was the relative incidence of righthemisphere
language dominance, and vice versa (Fig. 3).
Overall, strong left-handers demonstrated a nearly sevenfold
higher incidence of right-hemisphere language dominance
than strong right-handers. In extreme left-handers the
incidence of right-hemisphere language dominance was 27%,
2514 S. Knecht et al.
Fig. 1 Schematic illustration of the fTCD procedure in a single subject. For comparison, an fMRI of the
same subject during an identical language task is shown (upper left). The fMRI analysis was performed
by statistical parametric mapping, using software from the Wellcome Department of Cognitive
Neurology, London, UK. fTCD measures the modulation of the cerebral blood ﬂow velocity (CBFV) in
the middle cerebral arteries (MCAs) at a depth of 50 mm during word generation. This allows the
assessment of activity-related perfusion changes in the vascular territories of the left (red) and right
(green) MCAs. These territories comprise potential language areas (van der Zwan et al., 1993). After a
cueing tone (Cue), a letter (Letter) is presented on a computer screen and the subject has to ﬁnd silently
as many words as possible that start with the displayed letter. Task performance is controlled by having
the subject report the words (Speaking) after a second auditory signal, presented 15 s after presentation
of the letter. The averaging procedure used for fTCD is depicted schematically below. CBFV changes in
both MCAs during single runs (1 to n) of the language task are collected and averaged (usually a total
of 20 runs). Subtraction of averaged CBFV changes in the right and the left MCA provides a measure
of the mean interhemispheric difference in CBFV. The mean interhemispheric CBFV difference curve is
time-locked to ﬁxed events during the task. Calculation of the laterality index during word generation
(LI) is based on the maximal left–right difference during word generation. The LI is highly reproducible
and is proportional to lateralization, as assessed by fMRI and the Wada test (Deppe et al., 1997, 1998,
2000; Knecht et al., 1998a, b). Positive indices represent left-hemisphere language dominance; negative
indices represent right-hemisphere language dominance. In this subject, a positive value indicates lefthemisphere
lateralization for word generation.
Handedness and language dominance 2515
whereas in extreme right-handers it was 4%. The incidences
in the ﬁve intermediate groups were 27, 22, 11, 10 and 6%,
respectively (Fig. 3). The rate of right-hemisphere language
dominance can be approximated on the lowest order by the
formula: likelihood of right-hemisphere language dominance
(%) ϭ 15% – handedness by the Edinburgh Inventory (%)/10.
Gender analysis
ANOVA on the single and combined inﬂuences of gender
and handedness on language dominance showed no signiﬁcant
effect of gender (P ϭ 0.42 and P ϭ 0.29, respectively).
Analysis of familial handedness
As Table 1 shows, there was a trend for subjects with a
family history of left-handedness to have a higher incidence
of right-hemisphere language dominance. ANOVA on the
single and combined inﬂuences of familial handedness and
handedness on language dominance was limited by the small
subgroups and the skewed distribution of handedness (Ushaped)
and language dominance (bimodal). The single
inﬂuence of familial handedness and the combined inﬂuence
of familial handedness and handedness on language
dominance did not reach signiﬁcance (P ϭ 0.7 and P ϭ 0.9,
respectively). Familial handedness only showed a signiﬁcant
effect on handedness (P ϭ 0.006).
Fig. 2 Three-dimensional frequency histogram demonstrating the
number of subjects (z-axis) with a given degree of handedness
(y-axis) and language lateralization, as determined by fTCD
(x-axis), in a total of 326 healthy subjects, comprising 198
females (age range 15–49 years, mean 26, SD 5.5) and 128
males (age range 19–46 years, mean 26, SD 4.6). These subjects
include those reported in a preceding paper (Knecht et al., 2000).
Handedness was assessed by the Edinburgh Inventory
(Oldﬁeld, 1971) (positive values indicate relative righthandedness
and negative values indicate relative left-handedness).
Degree of language lateralization
In addition to the correlation between language lateralization
and handedness, a two-way interaction between the absolute
degree of language lateralization and the direction of
handedness was found, i.e. subjects in whom the side of
language dominance was the same as the side of dominance
in the control of dexterity had stronger lateralization than
those in whom these factors were dissociated: right-handers
with left language dominance and non-right-handers with
right language dominance displayed stronger overall
lateralization than right-handers with right language
dominance and non-right-handers with left language
dominance (ANOVA, P ϭ 0.04) (Fig. 4). Use of the
Kolmogorov–Smirnov test did not detect signiﬁcant
differences in the absolute degree of language lateralization
between right-handers with right language dominance and
non-right-handers (handedness Ͻ30) with left language
dominance (P Ͼ 0.1). Also, no signiﬁcant difference was
detected between right-handers with left language dominance
and non-right-handers (handedness Ͻ30) with right language
dominance (P Ͼ 0.1).
Discussion
This is the ﬁrst study to show that in healthy subjects there
is a consistent and almost linear relationship between the
degree of handedness and the direction of language
dominance.
The relationship between handedness and language
dominance has been addressed by Pujol and colleagues (Pujol
et al., 1999). Using a word generation task similar to ours,
they performed a two-slice fMRI examination focusing on
Broca’s speech area in 100 healthy volunteers. They found
frequent participation of the right Broca’s homologue in lefthanders.
Our results conﬁrm this ﬁnding. Additionally, they
show that the incidence of right language dominance depends
not only on the direction but also on the degree of handedness.
This relationship is consistent and linear. The present ﬁndings
also extend our own previous results on the variability of
language lateralization in moderate and strong right-handers
(Knecht et al., 2000). In this group, we had found a 7%
incidence of right-hemisphere language dominance. From the
present sample, almost twice the size of the earlier sample,
it is apparent that in strong right handers, i.e. those with a
handedness index of 100 according to the Edinburgh
Inventory, the incidence of right-hemisphere language
dominance drops to ~4%. In their series of patients with
medically intractable seizures, Rasmussen and Milner
categorized handedness as either (i) right or (ii) left or mixed.
Among patients without clinical evidence of early damage
to the left hemisphere, they reported right speech lateralization
by the amobarbital procedure in 4% of right-handers and in
15% of left- or mixed-handers (Rasmussen and Milner, 1977).
Because these data were drawn from a pathological cohort,
it remained unclear from this series whether the relationship
2516 S. Knecht et al.
Handedness –99 or less more than –99; more than –75; more than –25; more than 25; more than 75; more than 99
–75 or less –25 or less 25 or less 75 or less 99 or less
n 37 26 50 18 40 48 107
Right dominance (%) 27 27 22 11 10 6 4
Fig. 3 Relationship between the degree of handedness by the Edinburgh Inventory (x-axis) and the incidence of right-hemisphere
language dominance (y-axis). Bin width for each subgroup is represented by dotted horizontal lines. Error bars, represented by vertical
lines, are based on the formula:
(100 – P) P
σ ϭ
n√
The relationship between the rate of right-hemisphere dominance and handedness can be approximated by the formula: likelihood of
right language dominance (%) ϭ 15% – handedness (%)/10. Speciﬁc information on the subgroups [width of handedness categories by
the Edinburgh Inventory; number of subjects per category (n) and percent right dominance] is given in the table below the graph.
Table 1 Rate of right-hemisphere dominance in relation to parental left-handedness
Handedness of subject
–75 or lower Between 75 or higher
(strong left-handers) –76 and 75 (strong right-handers)
ϩ Ϫ ϩ Ϫ ϩ Ϫ
Parental left-handedness
n 14 43 13 88 10 145
Degree of handedness, –100 –100 –60 –10 100 100
median (quartiles) (–100, –90) (–100, –90) (–60, 50) (–52, 42) (100, 100) (89, 100)
Right-hemisphere language 29 23 15 17 10 4
dominance (%)
between handedness and dominance was a natural
phenomenon. Furthermore, because handedness had been
collapsed into only two categories, the data do not indicate
whether the observed relationship between handedness and
language dominance was categorical or linear. Overall, the
tendency reported by Rasmussen and Milner is in accord
with our data. However, the incidence of right-hemisphere
dominance for language was considerably higher in our
strongly left-handed healthy subjects (27%) than in the
group of left- or mixed-handed epilepsy patients from the
Rasmussen and Milner series (15%). This agrees well with
a linear relationship between the degree of handedness and
the incidence of right-hemisphere dominance for language.
Although fTCD has a low spatial resolution, it constitutes
a very practical tool to determine functional lateralization in
a large number of subjects. We used a strictly mathematical
distinction between right- and left-hemisphere language
dominance. This approach constitutes a gross simpliﬁcation
of the neural basis of language, but allowed us to focus on
the relationship of handedness with language lateralization.
A left-hemisphere fTCD lateralization index does not exclude
involvement of the right hemisphere; it only demonstrates a
Handedness and language dominance 2517
Fig. 4 Two-way interaction between the absolute degree of
language lateralization for left and right language dominance (and
standard deviations) in right-handers (handedness Ͼ30 by the
Edinburgh Inventory, circles) and non-right-handers (handedness
ഛ30 by the Edinburgh handedness inventory, asterisks).
relatively large increase in perfusion during word generation
by the left hemisphere. This mathematical distinction was
chosen to exclude the bias which is always involved when
deﬁning ‘bilateral’ language lateralization (Risse et al., 1997).
A more ‘bilateral’ lateralization, i.e. a lower degree of
lateralization, was found in subjects in whom dominance of
manual control (handedness) and dominance of language did
not fall into the same hemisphere (Fig. 4). This ﬁnding may
explain why in a large series of patients those with atypical
lateralization for handedness seemed to have slightly less
severe aphasia than patients with typical handedness (Basso
et al., 1990).
Although word generation is a frequently used activation
task and constitutes an essential feature in the production of
language, it is only one of the multiple dimensions of
language (Cuenod et al., 1995; Hertz-Pannier et al., 1997;
Benson et al., 1999). Other aspects of language, such as
prosody, were not tested in our study, and could therefore
show a different relationship with handedness.
For handedness, a genetic basis is established but does not
ﬁt a simple Mendelian model (Carter-Saltzman, 1980). This
suggests a role for complex genetic or non-genetic factors in
the formation of the phenotype (McManus, 1991; Annett,
1996). We assessed handedness with the Edinburgh Inventory.
This is a preference-based measure and shows a J-shaped
distribution of handedness in the general population. It differs
from the more bell-shaped distribution found by skill-based
measures, and it is susceptible to a cultural bias (Corballis,
1997). Because of its good test–retest reliability, the
Edinburgh Inventory has been used in many studies and,
unlike other measures, allows good comparison between
studies (Ransil and Schachter, 1994). Handedness can safely
be regarded as a two-directional phenomenon because
different measures of handedness usually show a close
relationship to each other, such that individuals classiﬁed as
left- or right-handers by one method are classiﬁed in the
same way by other methods (Corballis, 1997). Differences
in the grading system for handedness may bear on the shape
of the correlation with language dominance, but there is
little to suggest that this relationship would change in
a fundamental way if a different measure of handedness
were used.
The present study demonstrates that left-handedness is
neither a precondition nor a necessary consequence of righthemisphere
language dominance. However, left-handedness
increases the likelihood of right-hemisphere language
dominance. Furthermore, left-handedness in either parent
may have an additional effect on the likelihood of righthemisphere
language dominance (Table 2). The degree of
handedness is linearly and highly signiﬁcantly related to the
side of language dominance. Mathematically, this relationship
involves two variables and can be approximated by the
following formula: likelihood of right language dominance
(%) ϭ 15% – handedness (%)/10. In biological terms, such
a relationship is difﬁcult to explain by a single causative
factor. A more plausible explanation would be that handedness
and language dominance are each determined by multiple
factors, some of which have a role in both phenomena. Such
multiple and partly overlapping factors could produce (i) a
threshold effect accounting for the 4% incidence of righthemisphere
language dominance in extreme right-handers,
and (ii) a modiﬁer effect accounting for the increase in
incidence of right dominance along with the increase in lefthandedness.
The present study provides a framework for the
investigation of these factors. For example, assessment of
the inheritance of language dominance by functional imaging
may shed more light on the genetic underpinnings of
functional asymmetry in the human brain.
Acknowledgements
We wish to thank Drs F. Sto¨gbauer and I. Jacobi for their
comments and helpful discussions. We also wish to thank
Professor Dr W. L. Heindel and Dr K. Papke of the
Department of Radiology at Mu¨nster for their cooperation in
performing fMRI. One of these scans was used to illustrate
fTCD. This work was supported by the NachwuchsgruppenFo¨rderung
(S.K.: 2000-2005) and the Bennigsen-FoerderPreis
of Nordrhein-Westfalen (IVA 6-400 302 97), the
Innovative Medizinische Forschung of the Medical Faculty
at Mu¨nster (Kn-1-1-II/96-34 and KN 3 2 98 01) and the
Deutsche Forschungsgemeinschaft (Kn 285/4-1 and Kn 285/
6-1). Preliminary results of this study were presented at the
conference ‘The Science of Aphasia’, September 8–13, 2000.
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Received May 22, 2000. Revised August 15, 2000.
Accepted August 17, 2000