Assessing the Validity and Reliability of Two IMU Sensor Systems and a Goniometer in Multi-Planar Cervical Motion
Phase: NA
Conditions: Cervical Spine Motion Assessment in Healthy Adults
Sponsor: European University Cyprus

 
 
 
Study Protocol 
Assessing the Validity and Reliability of Two IMU Sensor Systems and a 
Goniometer in Multi-Planar Cervical Motion 
Introduction 
The head contains the peripheral vestibular system, a vital sensory system that 
contributes to balance control during both static and dynamic tasks (Hain & Helminski, 
2014). Accurate measurement of head posture and cervical range of motion (CROM) 
is also crucial for understanding spatial orientation and the integration of neural inputs 
from the semicircular canals and otolith organs, providing valuable insights for 
designing targeted vestibular rehabilitation strategies (Casado-Sánchez et al., 2025; 
Horak, 2006). CROM measurement is a key element in rehabilitation, as it informs 
clinical decisions, monitors patient progress, and supports discharge planning (Norkin 
& White, 2016). Objective biomechanical evaluation of cervical motion enables the 
detection of dysfunction and assessment of treatment outcomes, with broad 
applications in clinical practice, sports performance, ergonomics, and pain 
management (Haimovich et al., 2021). While extensive research has focused on other 
joints (Camargo et al., 2021; Rigoni et al., 2019; Scherpereel et al., 2023), cervical 
motion assessment remains an evolving field with growing relevance in both clinical 
and research settings (Keidan et al., 2025). 
The universal goniometer (UG) is widely used in various clinical settings, including 
physical therapy clinics, to assess range of motion (ROM) due to its ease of use, 
speed, and reasonable measurement accuracy (Brosseau et al., 2001; Gajdosik & 
Bohannon, 1987; Goodwin et al., 1992; Mayerson & Milano, 1984; Tucci et al., 1986). 
As a result, the UG is considered the gold standard for ROM assessment (Wilson-
Smith et al., 2022). However, despite its application in CROM measurement, UG has 
known limitations in accuracy and reproducibility. It requires trunk stabilisation to 
ensure pure CROM assessment, restricts measurements to predominantly upright 
positions, and limits clinicians' ability to evaluate neck CROM in diverse settings or  

 
 
 
during complex dynamic activities (Keidan et al., 2025). 
The advancement of optical motion capture (MoCap) systems, including both marker-
based and markerless technologies, has revolutionised human motion assessment. 
The marker-based optoelectronic system, widely regarded as the gold standard for 
human movement analysis, offers high accuracy, rapid data capture, and reliable 
multi-plane tracking of body segments (Cuesta-Vargas et al., 2010; Kimberlin & 
Winterstein, 2008). However, its complexity, high cost, time demands, and the need 
for minimal clothing and highly trained operators limit its use in real-world clinical 
settings (Cimolin et al., 2022; Miranda et al., 2013; Wade et al., 2022). In contrast, 
wearable inertial sensors provide a user-friendly, time-efficient alternative that allows 
clinicians and researchers to collect quantitative data on functional limitations while 
enhancing ecological validity (Kimberlin & Winterstein, 2008). 
Although the assessment of movement using IMU sensors has increased over the 
past decade, the measurement of angular movements has often proven problematic, 
with studies showing discrepancies in validity, a limited number of participants, or 
unreproducible results (Chan et al., 2022; Morrow et al., 2017; Rekant et al., 2022; 
Seong et al., 2024; Tolza et al., 2017; Wiles et al., 2023; Wong et al., 2015; Yoon et 
al., 2019). 
Aims 
Hence, this work aims to assess the validity and reliability of the CROM measurement 
obtained by two inertial sensor systems in a group of healthy individuals when 
compared to that obtained by the gold-standard assessment methodology of the UG 
and using photographic measurements (Yoon et al., 2019). The dataset will support 
the development of methods that enable the estimation of CROM from raw IMU data 
through static and functional calibration steps, thereby eliminating the common 
problem of drift, which most sensor fusion algorithms cannot completely address.  
 

 
 
 
Dealing with and eliminating drift is essential for maintaining accuracy in long-term 
monitoring and ensuring consistent data quality across various conditions and 
environments. Robust calibration methods ensure reliability in long-term usage, which 
is critical in both clinical and real-world settings. Furthermore, if Delsys sensors are 
employed, an additional benefit is the ability to record electromyographic (EMG) 
signals simultaneously. This eliminates the need for integrating separate IMU 
(accelerometer, gyroscope, magnetometer) and EMG systems via third-party data 
acquisition hardware, thereby streamlining experimental setup and improving data 
synchronisation (Karatsidis et al., 2017). 
Materials and Methods 
Participants 
The sample size estimation was conducted using G*Power 3.1 (Faul et al., 2007, 
2009) to ensure sufficient statistical power for validity assessment. In the present 
study, with N = 18, the minimum required correlation coefficient to achieve a power 
level of 0.80 at a significance level of p = 0.05 is 0.67. 
The sample will consist of participants without any neck pain, neck-related injuries, or 
cervical spine conditions in the past few years. Individuals with a history of 
musculoskeletal or neurological disorders, pain, balance disorders, or other 
symptoms that may hinder the execution of the tests will be excluded from the study. 
All participants will be required to sign a written informed consent form that provides 
a detailed description of the experimental tests. The study will be conducted in 
accordance with the Declaration of Helsinki, and the protocol will be approved by the 
Cyprus Bioethics Committee. 
Data Acquisition 
CROM Measurement 
Inertial Sensor System 1: Delsys Sensors 
The first inertial sensor system will consist of two surface wireless 3D Delsys Trigno 
Avanti sensors (Delsys Inc., Natick, MA, USA) embedded with EMG and IMU sensors,  

 
 
 
including a 3D accelerometer, a 3D gyroscope, and a 3D magnetometer. The EMG 
sensor has an input range of 11 mV or 22 mV, a bandwidth of 10–850 Hz, and a 
resolution of 16 bits. The accelerometer offers a range of ±16 g with a bandwidth of 
24 Hz to 473 Hz and a resolution of 16 bits. The gyroscope features a range of ±2000 
°/s, a bandwidth of 24 Hz to 360 Hz, and a resolution of 16 bits. The magnetometer 
has a range of ±4900 µT and a bandwidth of 50 Hz. The sampling rates for the sensors 
include an EMG sampling rate of 1,259 Hz, as well as sampling rates of 74 Hz for the 
accelerometer and gyroscope. IMUdata will be recorded using Delsys software, 
EMGworks Acquisition 4.5.4 (Delsys Inc., Natick, MA, USA), at a sampling rate of 74 
Hz. Data will be received as raw IMU data (3D acceleration and 3D gyroscope data 
on the local coordinate system of the sensor). 
Inertial Sensor System 2: Xsens Dot Sensors 
The second inertial sensor system will utilise two wireless Xsens DOT wearable 
sensors (Movella Inc., Enschede, The Netherlands). Each sensor contains a 3D 
accelerometer, 3D gyroscope, and 3D magnetometer. The gyroscope has a full-scale 
range of ±2000°/s, a bandwidth of 255 Hz, and a resolution of 16 bits. The 
accelerometer offers a range of ±16 g, with a low-pass filter cut-off frequency of 324 
Hz (262 Hz on the Z-axis) and a 16-bit resolution. Accelerometer and gyroscope 
sensors sample data internally at a rate of 800 Hz. The magnetometer operates with 
a full scale of ±8 Gauss, a sampling frequency of 60 Hz, and a resolution of 16 bits. 
During recordings, data can be saved onboard at rates up to 120 Hz, while real-time 
streaming is supported at rates up to 60 Hz via Bluetooth 5.0. Orientation data is 
computed using Xsens' proprietary XKFCore Kalman filter, which fuses data from 
magnetometer, accelerometer, and gyroscope to estimate drift-free 3D orientation. 
For this study, the Movella DOT mobile application will be used to control (start/stop), 
synchronise and collect orientation data as quaternion representations during the 
measurement. The data will then be exported post-session for further analysis. 
 

 
 
 
Goniometer 
A goniometer will be used as the gold standard reference device. Active ROM testing 
will follow the protocol recommended by Norkin and White (2016). A trained physical  
therapist experienced in using the UG will conduct the goniometer measurement 
acquisition. 
Data Collection 
Delsys sensors and Xsens Dot Sensors will be used to monitor the participant's neck 
movements throughout the study. Sensor 1 will be placed over the skin at the level of 
the T1 vertebra using double-sided adhesive tape, while Sensor 2 will be secured 
within a custom-fitted headband positioned around the participant's head. The 
headband will then be placed over the external occipital protuberance and the glabella 
to ensure stable sensor placement. In this configuration, the T1 sensor serves as a 
reference point representing thoracic posture, while the head-mounted sensor 
captures actual head motion. By computing the relative orientation between the two 
sensors, true CROM can be isolated, eliminating trunk or postural contributions. 
Sensor locations were selected based on previously published protocols with minor 
modifications (Keidan et al., 2025). 
To enable direct comparison and validation, Xsens DOT sensors will be placed 
adjacent to the Delsys sensors at the same anatomical locations, allowing for 
simultaneous data collection from both inertial sensor systems under identical 
conditions. 
Experimental Protocol 
Part A – Reliability Assessment (Upright and Forward-Leaning Positions) 
To establish the consistency and repeatability of both inertial measurement unit (IMU) 
systems, measurements will be performed under two conditions: lity will be assessed 
under two conditions: an upright seated position and a forward-leaning position, both 
of which are relevant to clinical and functional contexts. Performing reliability testing  

 
 
 
in multiple postures ensures that the system remains robust across varying 
biomechanical demands before proceeding to validity evaluation. 
In both positions, two wireless Delsys sensors and Xsens Dot Sensors will be used. 
Sensor 1 will be affixed to the skin overlying the T1 vertebra using double-sided tape, 
while Sensor 2 will be embedded within a tightly fitted headband positioned over the 
external occipital protuberance and the glabella. This configuration allows the system 
to detect true cervical motion by calculating the relative orientation of the head to the 
thoracic spine, excluding compensatory trunk movement. Before the start of the main 
trials, participants will also perform a brief calibration sequence consisting of static 
and slow functional neck movements to assist in aligning the Delsys sensors with the 
anatomical axes. 
Upright Position 
In an upright seated posture, participants will perform cervical movements across 
three planes: sagittal (flexion/extension) in Trial 1, frontal (left/right lateral flexion) in 
Trial 2, and transverse (left/right rotation) in Trial 3. Each movement will be repeated 
in a controlled manner for three cycles, with a 5-second hold at the end range and a 
return to neutral position. This protocol will allow for intra-session reliability analysis. 
A five-minute break will be included between the initial and repeated trials. During 
each trial, CROM will be simultaneously measured using both the IMU sensors and a 
UG, allowing for concurrent assessment of intra-session reliability and criterion 
validity. 
Forward-Leaning Position 
In this condition, participants will maintain a stable forward-leaning posture while 
seated on an SRM ergometer bike (Schoberer Rad-Messtechnik, SRM GmbH, 
Germany). The handlebars will be positioned low, allowing subjects to lean forward 
onto their forearms, achieving a nearly horizontal upper-body alignment. This posture 
has been chosen to reflect occupational and athletic body mechanics. 

 
 
 
Neck motion will again be assessed in the three anatomical planes: 
• 
Trial 4: Sagittal – Flexion and Extension 
• 
Trial 5: Frontal – Left and Right Lateral Flexion 
• 
Trial 6: Transverse – Left and Right Rotation 
Trials 4–6 correspond to the same movement sequences used in Part A and are not 
separate data collection sessions. Each movement will be repeated three times, with 
controlled timing and return to neutral, using the same protocol as in the upright trials. 
A retest will be conducted after a five-minute rest. Though the sensor placements will 
remain the same, changes in body orientation may affect the inertial frame, potentially 
influencing the sensor outputs. Thus, this part of the study ensured that posture-
induced variability was accounted for in the system's performance evaluation. 
Together, the two reliability conditions provide a comprehensive understanding of the 
IMU system's stability across clinically and functionally relevant postures. 
Part B (Validity) 
The validation protocol will be conducted with participants sitting upright (vertically) in 
a chair equipped with back support and armrests. Per the UG angle testing protocol, 
participants will be instructed to sit up straight, ensuring both feet are firmly and flat 
on the floor. Additionally, they will be guided to position themselves as far back in the 
chair as possible while maintaining a neutral sitting position with the thoracic and 
lumbar spine well supported by the chair back (baseline). Arms will remain rested on 
the armrests throughout the protocol. The chair used in the study will remain 
consistent throughout (40 cm x 40 cm x 45 cm) and will be placed in the same location 
in the room. The electromagnetic field (EMF) will also be tested prior to the study, with 
minimal EMF detected at the chair and SRM placement sites. 
To reduce participant burden and ensure consistency, criterion validity will be 
assessed using the UG measurements recorded concurrently during the reliability  

 
 
 
trials described in Part A. These values will be compared with the corresponding IMU-
derived angles. Cervical movements will be performed in the three anatomical planes: 
sagittal (flexion/extension), frontal (left/right lateral flexion), and transverse (left/right 
rotation), as already described. Movements will follow the same protocol as described 
in Part A. The mean of the three repetitions will be used as the representative value 
for each direction. 
Each trial will begin with 20 seconds devoted to calibration, during which the 
participant will be statically seated to establish baseline. A trained physiotherapist will 
align the UG during each repetition to obtain concurrent ROM values, ensuring 
consistent anatomical alignment across repetitions. Goniometric measurement will 
follow the protocol recommended by Norkin and White (2016) and will be applied 
during the same trials used for IMU data acquisition. This will ensure a direct one-to-
one comparison for the validity analysis. The validity of the UG device requires an 
upright vertical position to achieve textbook, gold-standard use. Part A (Forward-
Leaning Position) of the study will not use UG, so it will not limit movement analysis. 
This allowed for smoother motion and the addition of another plane of motion. By 
testing both vertical and horizontal planes, the study provided a more complete 
understanding of CROM. 
Data Analysis 
Raw IMU data and orientation data will be collected from the two inertial sensor 
systems, respectively: Delsys Trigno and Xsens DOT. Data from both systems will be 
exported as CSV files and processed using MATLAB (version R2024b, MathWorks 
Inc., Natick, MA, USA) via custom-developed scripts. For the Xsens DOT sensors, 
orientation will be derived from the provided quaternion data, with an initial calibration 
step applied to normalize the neutral head posture to zero degrees. 
For the Delsys Trigno sensors, raw accelerometer and gyroscope data will be used. 
A two-step calibration procedure will be applied: (1) the IMU data during the static  

 
 
 
postures will be used to estimate anatomical axes based on gravity, and (2) the data 
from the slow functional neck movements will be used to refine axis estimation using 
principal component analysis (PCA). These axes will be used to define a 
transformation matrix between each sensor's local frame and the anatomical frame 
(sensor to segment calibration). Joint angles between the head and torso will then be 
estimated using transformed sensor data, based on the relative orientation of 
anatomical axes derived from gravity and through integration of the gyroscope data 
for the rotational motions where gravity cannot be captured. This approach avoids 
direct sensor fusion and enables robust joint angle estimation using carefully designed 
calibration procedures. This processing pipeline ensures reliable and consistent angle 
estimation for neck range of motion tasks using both sensor systems. 
Statistical Analysis 
Part A 
A test-retest protocol will be implemented to assess relative reliability. Relative 
reliability will be evaluated using the intraclass correlation coefficient (ICC), which will 
be calculated using a two-way random-effects model with absolute agreement for 
single measurements. The interpretation of correlation strength will follow Cohen's 
(2013) guidelines, where values between 0.10–0.29 are considered a small effect, 
0.30–0.49 a medium effect, and ≥ 0.50 a large effect. In addition to the intraclass 
correlation coefficient (ICC), the Standard Error of Measurement (SEM) and the 
Minimal Detectable Change (MDC) will be calculated to evaluate absolute reliability 
and interpret the clinical relevance of measurement error. The SEM will be calculated 
using the formula: SEM = SD × √(1 - ICC), where SD will represent the pooled 
standard deviation of the repeated measurements. SEM will reflect the typical error 
expected in repeated assessments and will be expressed in the same units as the 
outcome measure. Lower SEM values will indicate greater measurement precision. 
To determine the minimum detectable change at a 95% confidence level, the formula 
MDC95 = 1.96 × √2 × SEM will be used. MDC will represent the minimum amount of 
change required to be 95% confident that it exceeds measurement error and reflects  

 
 
 
a true change. This will be particularly useful for clinical interpretation when monitoring 
progress over time. 
Part B 
To assess the measurement validity, data from the two IMU systems will be compared 
to the gold standard non-invasive UG. Analyses will be conducted using SPSS v27 
and Python. All outcome measures will be tested for normality and homogeneity of 
variance. Validity will be assessed using the Pearson product-moment correlation 
coefficient between the UG and each IMU. Additionally, modified Bland-Altman 
analyses, incorporating random effects models to account for repeated measures, will 
be employed to evaluate the agreement among the three measurement methods, 
thereby enhancing the precision of within-subject variance estimation. 
Ethical and Bioethical Considerations 
The sensors are non-invasive and pose no risk to the user. The only data to be stored 
will be the user's CROM measurements. The measurements will be stored 
anonymously; there are no concerns regarding personal data protection (GDPR). No 
personal user data will be stored. 
Study Timeline 
The data collection is expected to commence in July 2025 and be completed by 
September 2026. Data analysis and interpretation will follow, with the final report 
prepared by December 2026. 
Consent and Right to Withdraw 
Participation in this study is entirely voluntary. Individuals who agree to take part will 
be asked to carefully read the participant information sheet and provide written 
informed consent before any testing procedures begin. Participation involves non-
invasive measurement procedures using wearable sensors, conducted under the 
supervision of trained personnel. Participants may withdraw from the study at any  
 

 
 
 
time, without providing a reason and without facing any negative consequences. They 
may also request the removal of their data at any stage. To do so, they should contact 
the principal investigator, Dr. George Pamboris (G.Pamboris@euc.ac.cy), who will 
ensure that all personal data is immediately and permanently deleted without 
question. 
If participants have any concerns or wish to file a complaint, they may contact 
Professor Marios Vryonides, Vice Rector for Research and External Affairs at 
European University Cyprus. Full contact details for this independent contact person 
will be provided prior to participation, allowing direct communication outside the 
research team. 
Potential Benefits and Risks for Participants 
Although participants may not receive direct personal benefits from their involvement, 
their contribution to this research will play a valuable role in advancing scientific 
understanding of CROM) assessment. Specifically, the findings may inform 
improvements in diagnostic accuracy and rehabilitation strategies using wearable 
inertial measurement systems. These insights could support the development of more 
precise and ecologically valid tools for evaluating neck function and postural control, 
ultimately benefiting future clinical populations with cervical dysfunction or balance 
impairments. 
The study involves minimal risk. All procedures are non-invasive and limited to 
standard head and neck movements that participants perform in daily life. Minor 
discomfort, fatigue, or muscle stiffness may occur due to repeated or sustained 
postures, especially during the forward-leaning condition. To mitigate this, rest periods 
will be provided between trials, and participants will be allowed to stop the assessment 
at any point if they feel uncomfortable. 
No electrical stimulation or invasive techniques will be used. Sensors will be affixed 
using hypoallergenic, double-sided adhesive tape. While skin irritation is not  

 
 
 
anticipated, individuals with known skin sensitivities or allergies to adhesives will be 
excluded from participation. The protocol has been carefully designed to prioritise 
participant safety, with all procedures carried out under the supervision of trained 
professionals. 
Data Storage 
Electronic data will be stored on a password-protected computer. All personal data 
will be kept in a format that does not allow participant identification. Data will be 
anonymised using unique codes and stored electronically by Dr. Pamboris, who will 
be the only person with access to the file. Two years after the completion of the study, 
all data will be permanently deleted. After the study concludes, only the scientific lead 
will have access to the coded data. The data will be securely stored on Dr. Pamboris's 
personal storage device at European University Cyprus, in a locked digital folder. The 
university adheres to all prescribed electronic security measures to prevent any data 
theft from employee computers. In addition, all university premises are protected by 
a 24-hour private security presence. 
Study Results 
The results of the research project will be disseminated via a peer-reviewed scientific 
publication and presented at international scientific conferences. 
Complaints Procedure 
Participation in the study is voluntary, and participants may withdraw at any time 
without facing any negative consequences. Prior to participation, all participants will 
be informed of the independent contact person to whom they can submit any 
complaints or concerns. This person is the Vice Rector for Research and External 
Affairs of the European University Cyprus, Professor Marios Vryonides. Full contact 
details for the independent contact person will be provided before the study begins, 
allowing participants to communicate directly with them without involving the research 
team. 

 
 
 
Dr George M. Pamboris 
 
George Pamboris, PhD | Assistant Professor 
MSc Sports Physiotherapy Coordinator 
Department of Health Sciences 
[a] 6, Diogenes Str. Engomi, 2404 P.O.Box 22006, 
1516, Nicosia, Cyprus 
[t] +357 22713151 [f] +357 22559405 
[e] G.Pamboris@euc.ac.cy [w] www.euc.ac.cy 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
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