J Med Syst (2017) 41:7
DOI 10.1007/s10916-016-0645-8
MOBILE & WIRELESS HEALTH
Variability Analysis of Therapeutic Movements
using Wearable Inertial Sensors
Irvin Hussein López-Nava1 · Bert Arnrich2 · Angélica Muñoz-Meléndez1 ·
Arzu Güneysu2
Received: 23 May 2016 / Accepted: 19 October 2016
© Springer Science+Business Media New York 2016
Abstract A variability analysis of upper limb therapeu-
tic movements using wearable inertial sensors is presented.
Five healthy young adults were asked to perform a set of
movements using two sensors placed on the upper arm and
forearm. Reference data were obtained from three thera-
pists. The goal of the study is to determine an intra and
inter-group difference between a number of given move-
ments performed by young people with respect to the move-
ments of therapists. This effort is directed toward studying
other groups characterized by motion impairments, and it
is relevant to obtain a quantified measure of the quality
of movement of a patient to follow his/her recovery. The
sensor signals were processed by applying two approaches,
time-domain features and similarity distance between
each pair of signals. The data analysis was divided into
This article is part of the Topical Collection on Mobile & Wireless
Health.
 Irvin Hussein López-Nava
hussein@inaoep.mx
Bert Arnrich
bert.arnrich@boun.edu.tr
Angélica Muñoz-Meléndez
munoz@inaoep.mx
Arzu Güneysu
arzu.guneysu@boun.edu.tr
1 Department of Computer Science, Instituto Nacional de
Astrofı́sica, Óptica y Electrónica, 72840, Tonantzintla,
Mexico
2 Department of Computer Engineering, Bogazici University,
34342, Istanbul, Turkey
classification and variability using features and distances
calculated previously. The classification analysis was made
to determine if the movements performed by the test sub-
jects of both groups are distinguishable among them. The
variability analysis was conducted to measure the sim-
ilarity of the movements. According to the results, the
flexion/extension movement had a high intra-group variabil-
ity. In addition, meaningful information were provided in
terms of change of velocity and rotational motions for each
individual.
Keywords Therapeutic movements · Acceleration
signals · Quaternions · Wearable sensors · Inertial sensors
Introduction
Quantitative measures of human movement are important
for distinguishing both, healthy and pathological conditions
as well as for expressing the outcomes and changes that
are clinically important in the functional state of persons
[1]. In general, an important element in rehabilitation is to
obtain a quantified measure of the quality of movement of a
patient to follow his/her recovery and select the most appro-
priate therapeutic treatments. An objective quantification of
human movements contributes to better understanding the
patient condition, and might serve as a measure of efficacy
of the rehabilitation treatment [2].
Recent approaches that involve repetitive training of
the upper limb on task-oriented activities give evidence
of efficacy for actively improving the motor functions of
rehabilitation patients [3]. These repetitive training activ-
ities or therapeutic movements have to be provided by a
therapist with the aim that rehabilitation patients perform
7 Page 2 of 19
the same movement, following visual instructions, based on
repetition and practice [4].
The most frequently used instruments for the upper
limb functional assessment are clinical scales, that have
been standardized and validated previously. However, these
instruments have a high subjective component depending on
the observer who scores the test [1, 2]. Automated systems
for measuring human motion could provide to the therapist
numerical metrics to assess the patient’s recovery process
and potentially allow physiotherapists to assess the effec-
tiveness of various treatment protocols over a population of
patients [5].
However, patient data analysis for progress assessment
and monitoring is a challenging task because of the com-
plexity of human motion [6]. Human movement consists
mainly of continuous time variations of multiple degrees
of freedom (DoF), making single DoF comparisons incom-
plete and unreliable [7]. Also, human motion shows signifi-
cant temporal and spatial variability for different repetitions
of the same therapeutic movement. Additionally, human
characteristics such as age, gender, height, and weight,
increase the difficulty in the measurement and evaluation of
such movements.
To investigate the feasibility of measuring and assessing
functional upper limb motion, we analyze five therapeutic
movements performed by asymptomatic young persons in
contrast to reference data from therapists. It is important
to remark that the motion analysis of healthy persons is a
first step towards studying the mobility of patients in reha-
bilitation. This research addresses the following research
questions:
1. How similar are the movements of young persons with
regard to movements of therapists?
2. What is the variability of the subjects of the same group
performing a set of movements?
3. Which of the studied movements have greater and lesser
intra and inter group variability?
In this study the therapeutic movements are provided
by a group of therapists, whose movements can be used
as base of comparison for several study groups. The ulti-
mate objective is establishing a comparison of movements
performed by rehabilitation patients against movements per-
formed by therapists. However, patients on rehabilitation
may present greater movements variability due to different
factors including the individual effect of physical therapies,
or the widely dispersed intra group range of motions. Is
expected that the intra and inter therapist’s variability will
be lower than any other group because they are specialists
trained in methods for treating mobility impairments. In this
regard, it is necessary to evaluate the mobility of an interme-
diate group between specialists and patients with mobility
J Med Syst (2017) 41:7
impairments to assess their mobility relative to reference
data. This intermediate group might be composed of healthy
people who are non therapists and who do not have mobility
impairments either.
For that, this study can contribute to understand how
young persons perform therapeutic movements using com-
putational techniques applied to sensor signals. This effort
is directed toward studying in the future other groups char-
acterized by motion impairments.
The rest of the paper is organized as follows.
Section “Related work” addresses related work. Sec-
tions “Experimental setup” and “Data processing” describe
the experimental setup and data processing applied in this
study. Sections “Inter-group classification analysis” and
“Intra and inter-group variability analysis” give details
of the classification and variability analysis. Finally,
Sections “Discussion” and “Conclusions” close with the
discussion about the results, trends and applications of this
study.
Related work
There are some techniques to measure and assess the upper
limb movements of patients in rehabilitation, robot-based
systems [8–11], vision computer methods [12–15], among
others. Also in recent years, there has been an increasing
interest in designing wearable devices to monitoring and
training rehabilitation [16–18, 20].
Concerning the wearable sensors approach, Uswatte
et al. [16] evaluated the reliability and validity of accelerom-
etry for measuring upper limb rehabilitation outcome. 10
patients with stroke were asked to wear an accelerometer
on each arm, the chest and the more affected leg, before
and after the treatment. Also, 10 volunteers with stroke par-
ticipated in the study as control group. In the treatment
group, there was a significant increase from pre- to post-
treatment, while in the control group the change was not
significant. The movement recorded by each accelerometer
was used for assessing whether or not rehabilitation has an
effect on arm function outside the laboratory. Moreover, the
cited study suggests that just two accelerometers are ade-
quate for assessing whether rehabilitation has an effect on
arm function outside the laboratory.
Van der Pas et al. [17] studied the validity of accelerom-
etry in the assessment of arm activity of patients with
impaired arm function after stroke. They placed two
accelerometers on the wrists of 45 patients for measuring
the amount of upper extremity activity in daily life. The
magnitude of the vector of acceleration was calculated and
used as representation of the movement intensity across
time. Clinical scales were used as external criterion to test
J Med Syst (2017) 41:7
Fig. 1 Sequence of a movement
performed by a test subject with
the two sensors placed on the
upper limb. The movement is
touching with the hand the
posterior neck. Figs. (a) and (c)
show a subject in the initial
position with the right upper
limb static, and Fig. (b) shows
the situation when the subject
reaches the posterior neck with
the hand
the concurrent validity of arm accelerometry data. The cited
study revealed that both unilateral (activity of the affected
arm) and bilateral (ratio between the activity of the affected
and non-affected arm) accelerometry are valid methods to
assess arm activity after stroke.
Parnandi et al. [18] worked on wearable sensor-based
assessment of motor function in post stroke individuals. In
this study 1 participant wore a sensor on the wrist in order
to estimate the functional ability (FA) score of a clinical
test and compared it to the assessment given by a therapist.
Then, statistical features were extracted from acceleration
signals and a classifier was used for the estimation of the
functional ability scale. The results showed that the affected
arm has more information content at higher frequencies as
compared to the unaffected arm, which corresponds to the
involuntary motion. Also, the automated system is able to
compute the FA score to a good level of accuracy.
Fig. 2 Configuration of the two Exel sensors on the upper limb of
subjects, x-axis of both sensors are aligned with the sagittal plane of
the subject, y-axis and z-axis are both aligned with the transverse and
frontal plane, respectively
Page 3 of 19 7
Zhang et al. [19] proposed an approach using inertial
sensors to quantitatively evaluate the motor function of
the patients with stroke. The sensors were placed on the
forearms of 3 persons, including 1 healthy subject, during
5 motor task for capturing detailed patterns and intrinsic
characteristics exhibited in their movements. Acceleration
and angular velocities signals were used for extracting fea-
tures and for comparing motion trajectories. The results
show the effectiveness in capturing the detailed patterns
that standard clinical scores fail to reflect. This is useful to
clinicians for tracking the progress of the patients during
rehabilitation.
Recently, Strohrmann et al. [20] investigated changes
in the movement capacity during defined motor tasks.
They used 10 wearable sensors placed on the body and
conducted experiments involving 4 children with motor
function impairments. Data analysis consisted in extracting
features from the sensor data, linear acceleration and angu-
lar velocity, and applying a regression analysis to assess the
motor function in comparison with the assessment of the
experts. The results achieved in this research show a low
error and a good correlation between estimated values and
the experts’ ratings. The sensors that provide the most valu-
able information were those placed on each wrist and the
hip.
In this study, we propose the use of wearable inertial sen-
sors to characterize the movements of upper limbs in five
therapeutic movements, using time-domain features and
similarity distances from linear acceleration and orientation
signals. The purpose of this study is to analyze the variabil-
ity of healthy young subjects, as a particular case study, with
respect to reference movements of therapists. This research
is oriented to comprehend the basis that enable later the
study of the movements of specific pathological groups.
It will also serve as basis for a subsequent comparison of
groups of healthy and non-healthy subjects.
7 Page 4 of 19 J Med Syst (2017) 41:7

Fig. 3 Graphical representation of data analysis. Data flow: A and
B are acceleration and orientation signals from sensors placed on
the upper arm and the forearm, respectively; C are normalized sig-
nals segmented by each repetition of the five movements; D are nine
time-series features of each segmented signal used for inter-group clas-
sification analysis; E is only the feature mean of each segmented signal
used for inter and intra-group variability analysis; and F are distances
between each pair of segmented signals using DTW algorithm that are
used for inter and intra-group variability analysis

Experimental setup 5. Touching with the hand the opposite shoulder.

Therapeutic movements and subjects
Five movements were selected by three therapists since
these movements are focused on physiotherapy actions to
increase functionality of the upper limbs of persons [21].
The five therapeutic movements are listed below:
1. Touching with the hand the lower back.
2. Touching with the hand the posterior neck.
3. Pronation and supination of the forearm.
4. Flexion and extension of the arm.
The movement 3 consisted in performing the complete
range of motion of pronation of the forearm, and then return
to the initial position performing the supination, whereas
the movement 4 consisted in the flexion of the arm verti-
cally up and then return to the initial position performing
the extension. Movements 1, 2 and 5 consisted in mov-
ing the upper limb from the initial position up to touching
the lower back, the posterior neck or the opposite shoulder,
respectively, and then returning the upper limb to the initial
position. An example of a movement sequence (movement
2) is illustrated in Fig. 1. Figure 1a and c show the situation

Table 1 Classification results of the five movements and three data treatments using J48 algorithm

Movement Data TPR (sensitivity) TNR (specificity)

Touching the lower back Acc 0.93 0.93

Quat 0.97 0.97
Acc+Quat 0.95 0.93

Touching the posterior neck Acc 0.81 0.81

Quat 1.00 1.00
Acc+Quat 1.00 1.00

Pronation/supination of the forearm Acc 0.96 0.96

Quat 1.00 1.00
Acc+Quat 1.00 1.00

Flexion/extension of the arm Acc 0.99 0.99

Quat 1.00 1.00
Acc+Quat 1.00 1.00

Touching the opposite shoulder Acc 0.83 0.82

Quat 0.99 0.99
Acc+Quat 0.99 0.99
J Med Syst (2017) 41:7 Page 5 of 19 7

Table 2 Classification results of the five movements and three data treatments using Naı̈ve Bayes algorithm

Movement Data TPR (sensitivity) TNR (specificity)

Touching the lower back Acc 0.99 0.98

Quat 0.99 0.98
Acc+Quat 0.99 0.98

Touching the posterior neck Acc 0.88 0.89

Quat 1.00 1.00
Acc+Quat 1.00 1.00

Pronation/supination of the forearm Acc 1.00 1.00

Quat 1.00 1.00
Acc+Quat 1.00 1.00

Flexion/extension of the arm Acc 0.88 0.92

Quat 1.00 1.00
Acc+Quat 1.00 1.00

Touching the opposite shoulder Acc 0.80 0.83

Quat 1.00 1.00
Acc+Quat 1.00 1.00

when a subject is in the initial position with the right upper For this study data from two groups was considered.
limb static and Fig. 1b shows the situation when the subject Therapists group: data captured from movements of three
reaches the posterior neck with the hand. therapists, that was used as reference (from now on referred

Table 3 Classification results of the five movements and three data treatments using Logistic regression algorithm

Movement Data TPR (sensitivity) TNR (specificity)

Touching the lower back Acc 0.99 0.99

Quat 0.97 0.96
Acc+Quat 0.99 0.98

Touching the posterior neck Acc 1.00 1.00

Quat 1.00 1.00
Acc+Quat 1.00 1.00

Pronation/supination of the forearm Acc 1.00 1.00

Quat 1.00 1.00
Acc+Quat 1.00 1.00

Flexion/extension of the arm Acc 1.00 1.00

Quat 1.00 1.00
Acc+Quat 1.00 1.00

Touching the opposite shoulder Acc 0.94 0.94

Quat 1.00 1.00
Acc+Quat 1.00 1.00
7 Page 6 of 19 J Med Syst (2017) 41:7

Fig. 4 F-measure result of

classification of five movements
in both groups: therapists and
non-therapists, from the three
classifiers

as T 1, T 2 and T 3), and Non-therapists group: data captured
from movements of five subjects without mobility prob-
lems, mean age 32 ± 2.3 years (from now on abbreviated
as NT 1 to NT 5). All subjects have a dominant right arm.
Each movement was repeated ten times by each subject of
both groups.
Sensors and data
Two EXLs3 sensors (EXEL srl, Bologna, Italy) were used
in this study to measure upper limb motions. The EXLs3 is a
miniaturized electronic device with the function of real-time
Inertial Measurement Unit. It features a complete MEMS

a b
Fig. 5 Intra and inter group variability analysis from mean feature of acceleration signals of (a) the upper arm, and (b) the forearm, of both
groups: non-therapists group (dashed lines) and therapists group (solid lines)
J Med Syst (2017) 41:7
sensor set, which is composed by a tri-axial accelerometer,
gyroscope and compass, a 32-bit microprocessor for data
processing and a Bluetooth radio to send real-time data.
The size of the module is 54mm × 33mm × 14mm and its
weight is 22g.
Sensors were placed on two anatomical references of the
upper limbs of the test subjects. The first anatomical ref-
erence was located 10 cm up to the right elbow joint, in
the lateral side of the upper arm aligned the x-axis and
z-axis of the sensor with the sagittal and frontal plane of
the subject, respectively. The second anatomical reference
was located 10 cm up to the right wrist joint, in the pos-
terior side of the forearm following the coordinated system
of the sensor fixed on the upper arm. The sensors were
firmly attached to the upper limb segments using elastic vel-
cro straps. The coordinated system of the sensors is shown
in Fig. 2.
From each sensor: linear acceleration data (AccX, AccY ,
AccZ) and orientation data (QW , QX, QY , QZ) in quater-
nions were recorded. The sampling rate of the sensors was
100 Hz.
a b
Fig. 6 Intra and inter group variability analysis from mean feature of orientation signals of (a) the upper arm, and (b) the forearm, of both groups:
non-therapists group (dashed lines) and therapists group (solid lines)
Page 7 of 19 7
Data processing
In order to analyze the variability of data recorded from iner-
tial sensors in both groups, two approaches were used for
data processing. In Fig. 3 a graphical representation of data
analysis is presented. Acceleration and orientation signals
of the sensors placed on the upper arms and forearms (A and
B, respectively) were segmented and normalized according
to the number of repetitions, from a total of ten repeti-
tions for each movement. Segmented signals (C) are used
as input of both data processing approaches: time-domain
features extraction and distance calculation between signals.
Time-domain feature extraction consists in calculating a
measure that represents each segmented signal, see Section
“Extraction of time-domain features”. Distance calculation
consists in estimating a similarity measure between pair
of segmented signals, see Section “Calculation of distance
measure” for a detailed explanation. Then, the features
extracted (D) were used for classifying data into thera-
pists and non-therapists, see Section “Inter-group classifi
cation analysis” for a detailed explanation; and one feature
7 Page 8 of 19
Fig. 7 DT W mean distances of
acceleration signals for
therapists and non-therapists
subjects of the movement:
touching the posterior neck with
the hand
(E) and distances (F) were used for variability analysis,
see Section “Intra and inter-group variability analysis”. A
detailed description of these steps is presented below.
Extraction of time-domain features
In the first data processing approach, nine time-domain
series features were calculated for each segmented signal.
These features are divided into two groups: central tendency
and dispersion features. Central tendency features include:
arithmetic mean and median. Dispersion features include:
standard deviation, variance, root mean square, interquartile
range, mean absolute deviation, minimum and maximum.
Further details are listed in the Appendix.
Calculation of distance measure
For the second data processing approach, a distance was
measured from segmented signals using Dynamic Time
J Med Syst (2017) 41:7
Warping (DTW) algorithm. DTW is an algorithm capable of
measuring similarity between two temporal sequences that
vary in time [22]. DTW matches two time signals by com-
puting a temporal transformation aligning the signals. This
alignment is optimal in the sense that a cumulative distance
measure between the aligned samples is minimized [23].
For each pair of segmented signals, X and Y , of length m
and n, respectively, where X = {x1 , x2 , ..., xi , ..., xm } and
Y = {y1 , y2 , ..., yj , ..., yn } a matching cost DT W (X, Y )
is required. The matching cost was computed based on
dynamic programming using Eq. 1.
⎧ ⎫
⎨ (i − 1, j − 1) ⎬
D(i, j ) = d(xi , yj ) + min (i − 1, j ) (1)
⎩ ⎭
(i, j − 1)
where the distance function d(·, ·) is the Manhattan distance
(L1 -norm) used as cost measure and is defined in Eq. 2.
d(xi , yj ) = |xi − yj | (2)
J Med Syst (2017) 41:7
Fig. 8 DT W mean distances of
orientation signals for therapists
and non-therapists subjects of
the movement: touching the
posterior neck with the hand
and consequently the dynamic time warping distance
between a pair of signals is DT W (X, Y ) = D(m, n).
Inter-group classification analysis
For the classification analysis based on the nine features
extracted, three algorithms were used to classify the data
into two classes: therapists and non-therapists. The objective
of this analysis was to evaluate if the movements performed
by the test subjects of both groups are distinguishable
among them.
The classification algorithms selected were J48 classi-
fier, Naı̈ve Bayes and Logistic regression models. Naı̈ve
Bayes, a statistical classifier, has been shown to be success-
ful and simple for classification purposes. This algorithm is
Page 9 of 19 7
based on the Bayes’ theorem using the joint probabilities
of sample observations to estimate the conditional prob-
abilities of classes given an observation [24]. J48 is an
implementation of the C4.5 decision tree classifier [25], that
builds a binary classification tree. Determined by a split-
ting criterion, attributes are selected as branching points
that separate the two classes in the training dataset. Finally,
Logistic Regression is a generalized linear model to apply
regression to categorical variables. Generalizations of logis-
tic regression apply to multi category responses and assume
a multinomial distribution [26]. The selection of the algo-
rithms was based on the main classification approaches used
in the field.
The inter-group classification was performed for each
movement individually, dividing data into three treat-
ments: acceleration data (9 f eatures × 3 acceleration
7 Page 10 of 19 J Med Syst (2017) 41:7

Table 4 DT W acceleration mean distances of the five movements from both groups: therapists and non-therapists

Movement Sensor Therapist group mean (sd) Non-therapist group mean (sd)

Touching the lower back Upper arm 0.24 (0.03) 0.30 (0.09)
Forearm 0.63 (0.21) 0.45 (0.05)

Touching the posterior neck Upper arm 0.28 (0.05) 0.46 (0.09)
Forearm 0.62 (0.05) 1.61 (0.56)

Pronation/supination of the forearm Upper arm 0.08 (0.02) 0.10 (0.03)

Forearm 0.56 (0.35) 0.28 (0.14)

Flexion/extension of the arm Upper arm 0.32 (0.11) 1.77 (1.77)

Forearm 0.58 (0.17) 0.66 (0.19)

Touching the opposite shoulder Upper arm 0.24 (0.03) 0.30 (0.09)
Forearm 0.63 (0.21) 0.45 (0.05)

signals × 2 sensors = 54 attributes), orientation data
(9 f eatures × 4 orientation signals × 2 sensors =
72 attributes), and a combination of both (54 + 72 =
126 attributes). The number of instances of the ther-
apists group was 150 (3 subj ects × 5 movements ×
10 repetitions) and of the non-therapists group was 250
(5 subj ects×5 movements× 10 repetitions). For a model
evaluation, a 10 cross-fold validation was used.
Three metrics were calculated from the classification
results:
Sensitivity is the True Positive Rate (T P R), also called
Recall, and measures the proportion of positives which are
correctly identified as indicated in Eq. 3.
T rue positives
TPR =
T rue positives + F alse negatives
Specificity is the True Negative Rate (T NR) and mea-
sures the proportion of negatives which are correctly identi-
fied, Eq. 4.
T rue negatives
T NR = (4)
T rue negatives + F alse positives
F-measure (F) is the harmonic mean of recall and preci-
sion and is calculated applying Eq. 5.
2 (T P R ∗ P )
F = (5)
TPR + P
The result of classification from the three algorithms are
shown in Tables 1, 2 and 3. The columns show the metrics
that were calculated: true positive rate TPR and true nega-
tive rate TNR for each classifier; the rows show the three
(3)
data treatments for each therapeutic movement. In general,

Table 5 DT W acceleration mean distances of the three axis from both groups: therapists and non-therapists

Acceleration signal Sensor Therapist group mean (sd) Non-therapist group mean (sd)

X-axis Upper arm 0.27 (0.13) 0.45 (0.30)

Forearm 0.75 (0.13) 0.82 (0.60)

Y-axis Upper arm 0.21 (0.10) 0.95 (1.60)

Forearm 0.40 (0.12) 0.70 (0.75)

Z-axis Upper arm 0.21 (0.07) 0.35 (0.16)

Forearm 0.66 (0.11) 0.55 (0.26)
J Med Syst (2017) 41:7
Fig. 9 Intra a inter group
variability analysis from DT W
distances of acceleration signals
according to the movement
performed
the results of both metrics are consistent among them for
all movements. Logistic regression models can discrimi-
nate data of both groups using data of all treatments. J48
and Naı̈ve Bayes have the poorest results using acceleration
data.
Figure 4 plots mean scores of the F-measure using
the three classifiers for all treatments for the five move-
ments studied in our research. The movements that can
be classified more easily are touching the lower back and
pronation/supination of the forearm, which indicates a high
variability of the inter-group data. In other words, these
two movements performed by the subjects of non-therapists
group did not come close to those made by the thera-
pists. The next step was to conduct an intra-group analysis
to determine the variability of the movements within each
group, and thus to assess, through linear acceleration and
Page 11 of 19 7
angular orientation measures, how the movements were
performed by each subject.
Intra and inter-group variability analysis
The variability analysis was divided into two subsections
according to the data used. First, the time-domain feature
‘arithmetic mean’ was used for the comparison of both
groups from linear acceleration and orientation data of the
five movements. This analysis permit a visual difference
between all test subjects, and give us information about how
the movements are made with respect to the coordinated
system presented in Section “Sensors and data”. In the sec-
ond analysis an intra and inter-group variability analysis
was performed using the DTW distances of the movements
7 Page 12 of 19
performed by the subjects. This analysis allows to mea-
sure the similarity of the movements in two parts, the first
was evaluating which group has a major similarity inter-
group, and the second was evaluating which group has a less
similarity intra-group.
a group for upper arm data; however, forearm data of
b forearms of test subjects, and only data of subjects NT 1
Fig. 10 Intra a inter group variability analysis from DT W distances
of acceleration signals according to the acceleration signals
J Med Syst (2017) 41:7
Variability analysis using the feature mean
In this analysis a comparison between subjects of both
groups was performed using the time-domain feature ‘arith-
metic mean’ of linear acceleration and orientation signals,
recorded from sensors attached on the upper arm and
the forearm of the persons. Linear acceleration provides
information about the corresponding change in velocity
(speed increasing or decreasing over time) in one of 3 axis
(AccX, AccY, AccZ). Orientation provides information about
the rotational motion expressed in quaternions that are com-
prised by four scalars (QW, QX, QY, QZ), the vector part
(QX, QY, QZ) represents the orientation axis and the scalar
part (QW) corresponds to the rotation angle [27].
In Figs. 5 and 6 the means of linear acceleration and
quaternion signals of each subject are shown according
to the five movements. In particular, very short move-
ments were recorded from upper arm data for prona-
tion/supination of the forearm for both acceleration and
quaternions, because the upper arms of the subjects were
mainly static, as expected.
From acceleration data (see Fig. 5), touching the lower
back movement presents low variability intra and inter
group. Touching the posterior neck and touching the oppo-
site shoulder movements have similarity intra and inter
therapist T 2 show fewer acceleration than for the other
two therapists (T 1 and T 3) of two movements. Concerning
forearm data of touching the posterior neck movement,
the non-therapist group presents a high variability intra
group, only data of subjects NT 3 and NT 4 present low
variability with respect to to the data of therapist T 2.
Forearm data of touching the opposite shoulder move-
ment, data of subjects NT 1 to NT 4 present low vari-
ability with respect to the data of therapists T 1 and T 3.
Forearm data of flexion/extension of the arm and prona-
tion/supination of the forearm movements present similar
values intra group. Forearm data of pronation/supination
of the forearm movement present high intra-group simi-
larity as well as high variability inter-group. In particular,
upper arm data of flexion/extension of the arm move-
ment, data of subjects NT 1 and NT 3 have very high vari-
ability with respect to the other subjects non-therapists and
therapists.
From orientation data (see Fig. 6), the angular motion
recorded by the upper arms presents, in general, less
variability than the angular motion performed by the
and NT 4 present a high variability, as it was the case for
the acceleration signals. Only forearm data of touching
the posterior neck, pronation/supination of the forearm and
J Med Syst (2017) 41:7
Table 6 DT W orientation mean distances of the five movements from both groups: therapists and non-therapists
Movement Sensor
Touching the lower back Upper arm
Forearm
Touching the posterior neck Upper arm
Forearm
Pronation/supination of the forearm Upper arm
Forearm
Flexion/extension of the arm Upper arm
Forearm
Touching the opposite shoulder Upper arm
Forearm
flexion/extension of the arm movements have low variabil-
ity intra group. Forearm data of touching the lower back
movement present low values of rotation and a high inter
subject variability. In the forearm data of touching the
posterior neck movement, only data of subjects NT 1 and
NT 5 present low variability with respect to the data of ther-
apist group. Forearm data of pronation/supination of the
forearm movement, non-therapist group present very low
rotation values, indicating a high inter group variability. In
particular for forearm data of flexion/extension of the
arm movement, only data of subject NT 1 is closed to the
therapist group. Finally for forearm data of touching the
opposite shoulder movement, data of subject NT 2 is simi-
lar to the therapists T 1 and T 2, the rest of individuals of the
non-therapist group present very low variability with respect
to the therapist T 3.
Variability analysis using DT W distances
In this section, a variability analysis using data of the
second processing approach (see Section “Calculation of
distance measure”) is described. This variability analysis
shows the similarity of the movements made by the test
subjects, according to the acceleration and orientation sig-
nals. In contrast to the analysis based on the feature mean,
the DT W algorithm estimates a similarity measure between
two signals for comparing the motion magnitudes (linear
acceleration and orientation) along time.
In order to measure the similarity between the 7 differ-
ent signals (3 acceleration: AccX, AccY and AccZ, and 4
orientation: QW , QX, QY and QZ, acquired from the sen-
sors placed on the upper arm and the forearm of each
Page 13 of 19 7
Therapist group mean (sd) Non-therapist group mean (sd)
0.01 (0.01) 0.01 (0.00)
0.05 (0.03) 0.07 (0.03)
0.02 (0.01) 0.02 (0.01)
0.03 (0.01) 0.17 (0.06)
0.00 (0.00) 0.00 (0.00)
0.02 (0.02) 0.02 (0.00)
0.02 (0.00) 0.13 (0.08)
0.03 (0.02) 0.09 (0.05)
0.01 (0.01) 0.02 (0.01)
0.11 (0.11) 0.09 (0.06)
subject) the DT W algorithm was applied to each pair of
sequences of the same type of signal, i.e. each movement
was performed 10 times per each subject, then 50 sequences
were exhaustively evaluated using DT W .
Figures 7 and 8 illustrate examples of the mean distance
of ten repetitions of acceleration and orientation signals for
the movement: touching the posterior neck with the hand.
DT W distances from Upper arm and forearm data of
both groups are presented using diagonal matrices. In these
matrices, low distances represent big similarity, the bigger
the similarity, the darker the cell. It is also worth to remark
that in these matrices the groups corresponding to the intra
and inter group analysis are gathered.
Figure 7 indicates that a general high intra subject sim-
ilarity was found, except for the AccX acceleration signal
of the upper arm of the subject NT 3 and the forearm
of the subjects T 2 and T 3. There are three cases in which
a very low similarity of a subject from the rest is esti-
mated: AccY acceleration signal of the upper arm for
NT 3, AccY acceleration signal of the forearm for NT 5,
and AccZ acceleration signal of the forearm for NT 5 too.
Only AccX acceleration signal of the upper arm for the
therapist group present high intra group similarity.
In Fig. 8 a high intra subject similarity from orientation
signals can be observed in general. There is only one case in
which a very low similarity of a subject to the rest is deter-
mined, for the QZ signal of the forearm for NT 2. The
four signals of the upper arm and QZ of the forearm
present a high intra group similarity for therapist group,
which means that this movement was performed similarly
by the upper arm of the three therapists. In one case the
subject NT 1 had high similarity with respect to the therapist
7 Page 14 of 19
Table 7 DT W orientation mean distances of the quaternions from both groups: therapists and non-therapists
Orientation signal Sensor
QW Upper arm
Forearm
QX Upper arm
Forearm
QY Upper arm
Forearm
QZ Upper arm
Forearm
group, QX signal of the upper arm. In particular there
was only one signal indicating a high intra group similar-
ity for non-therapist group, QZ signal of the upper arm;
additionally an important inter group difference was deter-
mined, which means that the movements were performed
uniformly by the subjects within both groups, even though
were performed different by the groups.
The matrices of the other four movements were also cal-
culated. After that, the mean and standard deviation (sd)
were calculated for both groups from all the matrices in two
dimensions: by the five movements and by the sensor sig-
nals, for a total of three signals for acceleration and four
for orientation. Tables 4 and 5 show the DTW accelera-
tion mean distances of the five movements and of the three
acceleration signals from both groups, respectively.
According to Table 4, three movements present not only
high variability intra group, but also an inter group dif-
ference. These movements were forearm data of touch-
ing the posterior neck and upper arm data of flex-
ion/extension of the arm with low similarity of non-therapist
group, and forearm data of Pronation/ supination of the
forearm with low similarity of therapist group with respect
to the other group. These results are presented in box-plots
in Fig. 9. According to Table 5, only one signal presents
an inter group difference, corresponding to upper arm
data of Y-axis with low similarity of non-therapist group
with respect to the other group. However, the box-plots
of Fig. 10 show a low intra group variability for all sig-
nals, including the signal Y-axis of the upper arm data,
meaning that one of the therapists moved the upper arm at
different speed in comparison to the other two therapists.
Tables 6 and 7 show the DT W orientation mean dis-
tances of the five movements and of the four orientation
signals from both groups, respectively.
According to Table 6, two movements present a high inter
group difference. These movements were forearm data
J Med Syst (2017) 41:7
Therapist group mean (sd) Non-therapist group mean (sd)
0.02 (0.01) 0.05 (0.04)
0.08 (0.08) 0.11 (0.10)
0.01 (0.01) 0.03 (0.03)
0.05 (0.03) 0.06 (0.04)
0.02 (0.01) 0.06 (0.05)
0.03 (0.02) 0.09 (0.09)
0.01 (0.01) 0.02 (0.01)
0.02 (0.01) 0.10 (0.09)
of touching the posterior neck and upper arm data of
flexion/extension of the arm with low similarity of non-
therapist group with respect to the other group. These results
are presented in box-plots in Fig. 11; note also that a low
similarity of the forearm data of flexion/extension of
the arm of non-therapist group, with respect to the thera-
pist group, can be observed. In particular two movements
present high variability within both groups, forearm data
of touching the lower back and touching the opposite shoul-
der which means that this anatomical segment was rotated
differently by the subjects of both groups.
According to Table 7, three signals present high inter
group variability, and two of them also have high intra group
variability too. These signals are upper arm data of QX,
and forearm data of QY and QZ with a low similarity
of non-therapist group with respect to the therapist group.
The last two signals present a high intra group variabil-
ity as is shown in the box-plots of Fig. 12. In general, the
non-therapist group have a greater dispersion values in all
orientation signals, resulting in a wider range of motion of
the subjects of this group in comparison to the therapist
group. In only one case the dispersion value of therapist
group was grater than one for the non-therapist group, that
was forearm data of QW.
Discussion
The goal of this study was to measure and analyze the
therapeutic movements made by a young persons group
(non-therapists) with respect to reference data (therapists
group). First, a classification study was presented in order to
know if the movements performed by the subjects of these
groups are easily distinguishable. The classification results
show high F-measure values, 0.96 from J48 algorithm,
0.97 from Naı̈ve Bayes and 0.99 from Logistic regression
J Med Syst (2017) 41:7
Fig. 11 Intra a inter group
variability analysis from DT W
distances of orientation signals
according to the movement
performed
models. These values indicate that the measured move-
ments of the afore mentioned groups are distinguishable,
and that the movements made by non-therapists group are
not similar to the movements of reference data. For that rea-
son a detailed variability analysis was required, in order to
determine which subject properly performed the movements
according to the reference data, as well as knowing what
movements were executed correctly according to the linear
and angular measurements.
Two variability analysis were performed based on two
different approaches, the first using the feature ‘mean’ cal-
culated from segmented linear acceleration and orientation
signals, and the second using both segmented signals.
According to the results of the first approach, the three
non-therapist subjects NT 2, NT 3 and N5 performed the
movements as the three therapists with the upper arm,
Page 15 of 19 7
and only the subject NT 1 performed three movements:
touching the lower back, touching the posterior neck and
flexion/extension of the arm as the therapists T 1 and T 2
with the forearm, from linear acceleration data. These last
results are related to the speed with which the requested
movements were performed. From orientation data, subjects
NT 2 and NT 5 performed the movements as the three ther-
apists with the upper arm, and only the subject NT 1
rotated the forearm such as at least one therapist, except
for touching the posterior neck. In this last movement even
one subject rotated the forearm as the therapists. For touch-
ing the opposite shoulder movement, the five non-therapist
subjects rotated the forearm on two ways identified on the
therapist group.
According to the results of the second approach, from
linear acceleration data of upper arm, flexion/ extension
7 Page 16 of 19
Fig. 12 Intra a inter group
variability analysis from DT W
distances of orientation signals
according to the orientation
signals
of the arm movement had a high intra group variability
for non-therapist group; from data of forearm touching
the posterior neck and pronation/supination of the forearm
movements presented high intra group variability for non-
therapist and therapist group, respectively, indicating that
these movements were performed with different changes
of speed over time. From orientation data of upper arm,
flexion/extension of the arm movement had a high intra
group variability for non-therapist group, this variability
was caused by the rotation of the upper arm of some
J Med Syst (2017) 41:7
subjects of this group while the movement was performed;
from orientation data of forearm touching the lower back
and touching the opposite shoulder movements presented a
high variability inside both groups, so that the execution of
these two movements was different for all subjects in both
groups.
In general, therapist group present a lower intra-group
variability than non-therapist group according to the results
of both approaches. This intra-group variability can be
caused by the physiology of people, even inside the therapist
J Med Syst (2017) 41:7
group, e.g., the size of muscles, flexibility and restriction
of the joints, and the position of the sensors. Further-
more, results of inter-group variability can be caused by
misunderstanding of the verbal instructions or by the incom-
prehension of the therapeutic movements shown by the
therapists.
In addition, acceleration and orientation signals provide
meaningful information when comparing how the therapeu-
tic movements were performed by each subject with respect
to the reference data from therapist group, in terms of the
change of velocity and the rotational motions, respectively.
Moreover, for clinicians and therapists information about
both the rotational motions reached by patients and the
velocity of these movements is crucial for determining how
therapeutic movements are actually performed by different
groups of patients. These particularities might be associated
to fatigue, discomfort or even unwillingness experienced by
patients during their therapy [28].
Consequently, the information of variability provides
therapists meaningful information to analyze the variation
of particular therapeutic movements, and study if specific
known variations are associated to specific impairments, or
even if transitions in these variations can be established and
associated to the evolution of the patients.
Conclusions
An analysis of five upper arm therapeutic movements made
by young persons without mobility problems with respect to
reference data of therapists, was presented. The movements
were measured using two inertial sensors placed on upper
arms and forearms of the subjects. Two type of data were
used for the analysis, linear acceleration and orientation.
The linear acceleration and the orientation represent the
speed increasing/decreasing and the range of motion of the
movements performed by the test subjects. From these mea-
sures two approaches based on computational techniques
were applied in order to made an intra subject, and an intra
and inter group variability analysis.
These approaches and techniques can help to quantify
and compare objectively the motion of the patients with
respect to reference data for rehabilitation applications. In
th
some rehabilitation tasks it is important to measure the
progress of the range of motions of the upper limb seg-
th (7)
ments achieved by patients over time. In this regard,
this study contributes to gain knowledge on two important
aspects of rehabilitation. First, to quantify how the move-
ments performed by patients using their upper limbs are
Page 17 of 19 7
knowledge provide valuable feedback that can be used by
clinicians and therapists to customize rehabilitation therapy
to the very specific needs of patients.
This study aims to analyze aspects of the motion of peo-
ple without movement problems as a basis for subsequently
analyzing other groups characterized by limited movement,
such as elderly or patients in rehabilitation. Furthermore,
we plan to increase the sample size of healthy test subjects,
as well as selecting and applying appropriate clinical scales
scores to our experiments to provide more significance to
our findings.
A further advantage of the use of wearable sensors in
this area is their portability, so they can be used outside
controlled laboratories for health monitoring and remote
medical care in daily living environments. Finally, wearable
inertial systems enable data collection in the wild, for appli-
cations such as healthcare ecosystem, ambient intelligence
and smart environments, providing a convenient service for
patient-centric healthcare [29, 30].
Acknowledgments This work is supported by the Mexican National
Council for Science and Technology, CONACYT (grant number
271539/224405); and by the UBIHEALTH project, FP7-PEOPLE-
2012-IRSES, European Commission (grant 316337).
Appendix: Time-domain features
The time-domain features are divided into two groups: cen-
tral tendency (Eqs. 6 and 7) and dispersion (Eqs. 8–12), as
described below.
In all the formulas detailed below: n is the size of the
signal X, x is a value of X, th indicates the th-term of the
ordered time serie X, and Q1 and Q3 are the lower and
upper quartile of X.
– Arithmetic mean (x̄):
x1 + x2 + ... + xn
x̄ = (6)
n
– Median (f (x)):
⎧
⎪
⎨ n+1 term when n is odd
2
f (x) =
⎪
⎩( )
n th
2 term+ n+1
2 term
when n is even
2
– Standard deviation (σ ):

similar to reference movements. And second, to know how 1

σ = (x1 − x̄)2 + (x2 − x̄)2 + ... + (xn − x̄)2
these movements are actually performed by patients with n
respect to each one of reference individuals. Both pieces of (8)
7 Page 18 of 19
– Variance (σ 2 ):
1  therapy for long-term upper-limb impairment after stroke. New
σ2 = (x1 − x̄)2 + (x2 − x̄)2 + ... + (xn − x̄)2
n 11. Wei, X.J., Tong, K.Y., and Hu, X.L., The responsiveness and cor-
(9)
– Root mean square (rms):

1 2  12. Quintana, G.E., Sucar, L.E., Azcarate, G., and Leder, R.: Qual-
rms = x + x22 + ... + xn2 (10)
n 1
– Interquartile range (iqr):
iqr = Q3 − Q1 (11)
– Mean absolute deviation (mad):
1 ing a reach and grasp cycle for children. Gait Post. 32(1):72–77,
mad = [| x1 − x̄ | + | x2 − x̄ | +...+ | xn − x̄ |]
n 2010.
(12)
– Minimum is the smallest value of the sample
– Maximum is the largest value of the sample
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