Electroencephalography and clinicalNeurophysiology, 89 ( 1993) 359-362

359

1993 Elsevier Scientific Publishers Ireland, Ltd. 0924-980X/93/$06.00

EEM 93554

Technical note

Where to record motor activity: an evaluation of

commonly used sites of placement for activity monitors
J.J. Van Hilten, H.A.M. Middelkoop, S.I.R. Kuiper, C.G.S. Kramer
and R.A.C. Roos
Departments of Neurology and Clinical Neurophysiology, Academic Hospital, State University of Leiden,
2300 RC Leiden (The Netherlands)
( A c c e p t e d for publication: 30 J u n e 1993)

Summary
The aim of this study was to evaluate the role of the site of attachment of activity monitors. We compared mean diurnal and
nocturnal motor activity measures as well as the daily pattern of motor activity of dominant and non-dominant wrist recordings over 5 successive
days of 10 healthy right-handed and 10 left-handed subjects. In a second study we evaluated the relationship between truncal motor activity and
wrist motor activity. No differences emerged between the diurnal and nocturnal measures as well as the diurnal activity pattern of the dominant
and the non-dominant wrist. Additionally, no differences were found in relation to handedness. Our results show that it is inaccurate to regard
wrist motor activity measurements as.representative of an invariable percentage of truncal motor activity; the relation between the measurements
of these two recording sites varies across the daytime period. During the nocturnal period bilateral wrist motor activity occurred frequently in
absence of truncal motor activity. The reverse situation, however, may occur sporadically. This finding most likely reflects that integrated
generalized movements like postural shifts are measured at all recording sites, while the small movements that occur at the distal extremities are
predominantly recorded by wrist-worn monitors.
In conclusion, it is apparent that for both diurnal and nocturnal studies on the assessment of motor activity, either wrist can be chosen as the
recording site. Across the diurnal period the relation between motor activity recorded at the wrist and waist is subject to considerable variability.
During the nocturnal period motor activity can best be recorded at the wrist because this recording site detects both integrated generalized
movements and movements that occur at the distal extremities.
Key words: Motor activity; Recording; Activity monitor; Site of placement

The clinical utility of ambulatory activity monitoring in sleep,

behavioral, epidemiological and neurological studies has broadend
within recent years (Laporte et al. 1979; Aharon-Peretz et al. 1991;
Van Hilten et al. 1991, 1993; Hauri and Wisbey 1992). The advantages of the activity monitor largely derive from its potential to
record unrestrained motor activity for several days continuously,
while subjects live at home. Additionally, because of its small size
and weight, this monitor is minimally disturbing to individuals.
There are, however, no standardized criteria regarding the site at
which motor activity should be recorded. The majority of the studies
that focus on diurnal recordings use the non-dominant wrist as the
site of attachment of the monitor (Renfrew et al. 1987; Brown et al.
1990). Reasons for this choice are often lacking. In some studies,
however, the non-dominant wrist is chosen because of convenience
for the subjects investigated. Regarding sleep, the site of attachment
issue was adressed by Webster et al. (1982). Monitor placements at
the wrists were shown to detect the greatest amount of motor activity
compared to forehead and ankle attachment. Although the monitor
placement at the non-dominant wrist measured slightly more motor
activity than at the dominant wrist, the difference was considered to
be of little importance.

Correspondence to: J.J. Van Hilten, M.D., Dept. of Neurology,

Academic Hospital, P.O. Box 9600, 2300 RC Leiden (The Netherlands).
Tel.: 71-262104; Fax: 71-154537.

The problem remaining, however, is the site of attachment of the

monitor for diurnal studies. Therefore, in this study we compared
mean diurnal and nocturnal motor activity measures as well as the
daily pattern of motor activity as obtained from dominant and
non-dominant wrist recordings of 10 healthy right-handed and 10
left-handed subjects. In a second study we evaluated the relationship
between truncal motor activity and wrist motor activity.

Subjects and methods

The study was carried out in two parts. In the first study, motor
activity was recorded continuously for 5 days at both wrists of 10
left-handed (4 males; mean age 26.1 years, S.D. 8.1) and 10 righthanded subjects (7 males; mean age 30 years, S.D. 10.6). Handedness
was assessed with a questionnaire (Annet 1970), ambidexter subjects
were excluded. In the second study, motor activity was recorded
continuously for 3 days in 10 right-handed subjects (6 males; mean
age 30 years, S.D. 9.28) at both wrists and the waist to assess the
relationship between truncal and wrist motor activity. To measure
truncal motor activity a third monitor was suspended on a stretch
belt worn around the waist, positioned in the midline approximately
4 cm below the navel. All subjects were members of the University
community or were attracted by publicity describing the program.
They were in good health and had no history of sleep complaints.

360
Monitor
The characteristics of the activity monitor (Gaehwiler Electronic,
Hombrechtikon, Switzerland) used in this study have been reported
previously (Borb61y 1986; Van Hilten et al. 1991). Briefly, the device
counts supra-threshold motor activity (accelerations > 0.1 g) with
filtering of the analog sensor signal by a bandpass filter of 0.25-3 Hz
over 15 sec epochs. It stores the resulting sum as a 1-byte value in a
32-kbyte solid state memory. After completion of the recording, the
data are read out in a personal computer for analysis.
For this study 9 activity monitors were used. In order to synchronize each set of activity monitors they were initialized within 1 min
by the same computer. As the error of the crystal clock of the
monitors is minimal and timing errors by loading date and time from
one personal computer are at most 1 sec, the maximum synchronization error is about 1 sec.
Each monitor was calibrated on 3 occassions by a standardized
bench procedure to ensure comparability within and among the
devices. The monitor was mounted on top of a low frequency
speaker which produced up and down movements. The speaker was
connected to a low frequency oscillator which produced a sinusoidal
signal at a fixed frequency of 2.0+0.001 Hz, so that the response
within the bandwidth of interest may be recorded. The test mode of
the monitor interface was used to determine the threshold limit at
which the sine amplitude is measured. All activity monitors behaved
within the 3% range of the mean amplitude of each series. Between
3 different calibration series the mean amplitude behaved within the
1.5% range, without any tendency. The intra-instrument variability of
each activity monitor was less than 1%. Hence, the reliability of the
activity monitors was established by consistency between movement
and the monitor output signal on repeated trials. Measurements in
different directions showed a loss of sensitivity from the perpendicular (relative to the activity monitor groundplate) to sideways movements of 37-57%.
Recording procedures
We measured motor activity with an activity monitor continuously
from Monday 7 p.m. until Sunday 11 a.m. (first study), and from
Monday 7 p.m. until Thursday 7 p.m. (second study). Subjects were
asked to maintain their habitual 24 h pattern of activities and remove
the monitor only when taking a bath. During the recording period all
subjects kept a log. They recorded the time they switched off the
light to go to sleep, the time of definitive awakening, any naps, and
the time they removed the monitors.
Healthy subjects have a motor activity pattern characterized by 4
diurnal periods and a nocturnal period with different motor activity
levels: (1) the first 2 h after definitive awakening, (2) the remaining
part of the morning till 13:00 h, (3) the afternoon; 13:00 h-19:00 h,
(4) the evening; 19:00 h till lights out, and (5) the night; lights out till
definitive awakening (Renfrew et al. 1987; Brown et al. 1990; Van
Hilten et al. 1991). Therefore, for each of the 4 diurnal periods and
the nocturnal period the following measures were calculated for each
subject, and for each recording site.
(1) The activity level (AL), expressed as the mean number of
counts per 15 sec epoch.
(2) The movement index (MI), calculated as the number of
epochs with any movement (activity count > 0) expressed as a
percentage of all epochs that make up the period. The movement
index reflects the proportion of activity and immobility of a recorded
period.
For both measures the "mean" of each of the 5 periods across 5
days was calculated.
Statistical methods
The data were analyzed by a multivariate analysis of variance
(MANOVA) procedure (Statistic Package for Social Science PC + )
with a repeated measures design. The AL and MI are considered
dependent variables. The factor "subjects" is nested within the fixed

J.J. VAN HILTEN ET AL.

80

6O

[]

dominant wrist

[]

nondominsnt wrist I

[]

weis,

w
utl

.T_

.~ 40

20

/,

first 2 hrs morning

awake

afternoon

evening

night

Fig. 1. Mean (S.E.M.) motor activity levels of each recording site for
all diurnal and nocturnal periods. The graph shows a lower amount
of truncal motor activity and no differences between both wrists.

factor "recording site" and crossed with the fixed factor "diurnal
period." Accordingly, we investigated: differences between the
recording sites about.the mean values of the AL and MI (taken over
all diurnal periods), the existence of a diurnal pattern for these
parameters, and "recording site" differences about their diurnal
pattern. A similar design was used to evaluate the effects of handedness. The results of the nocturnal measures were analyzed with an
1-way ANOVA. Differences between means were tested by paired t
tests. P values < 0.05 are considered statistically significant.

Results
Dominant versus non-dominant wrist recording
For the mean diurnal and nocturnal values as well as the diurnal
pattern of the AL (Fig. 1) and MI (not shown) of the right- and
left-handed subjects no significant differences emerged between the
dominant and non-dominant recording sites (0.08 < P < 0.8). Only in
the right-handed subjects the dominant wrist recordings across all
diurnal periods showed slightly higher values than the non-dominant

16

"G

12

$_

11

0.0

AL

Idl

Fig. 2. Mean (S.D.) values of AL and MI during the nocturnal

period. * indicates a significant difference between wrist and truncal
motor activity values (P = 0.004).

WHERE TO RECORD MOTOR ACTIVITY

361
DOMINANT

NONDOMINANT WRIST

;i

WAIST

12

18

00

06

12

Fig. 3. A representative example of truncal and wrist motor activity

profiles over 24 h of a healthy right-handed subject. Note the
similarity between wrist and truncal motor activity patterns.

wrist recordings. During the nocturnal period, on the other hand, the
non-dominant wrist recordings measured slightly higher values than
the dominant wrist recordings. No differences were found for these
measures with regard to handedness (0.1 < P < 0.9).
Wrist recording versus waist recording
The mean diurnal values of the AL and MI of the waist are
significantly lower than those of the wrists (both measures; P < 0.01).
With regard to the diurnal pattern of the AL (Fig. 1) and MI (not
shown) of both wrists recordings showed a gradual but significant
( P < 0.01) decline across the diurnal periods (Fig. 1). On the other
hand, truncal motor activity showed no difference ( P > 0.5) across
the first 3 diurnal periods but declined prominently in the evening
( P < 0.05) (Fig. 1).
During the nocturnal period no differences were found for the
MI between the 3 recording sites ( P = 0.296). The AL values obtained from both wrists, however, were substantially higher (both
measures; P < 0.005) than that of the waist (Fig. 2).
Fig. 3 shows a representative example of truncal and wrist motor
activity recordings of one subject over 24 h. Note the similarity of the
truncal and wrist patterns. During the nocturnal period bilateral
wrist motor activity occurred frequently in absence of truncal motor
activity. The reverse situation, however, may occur sporadically.

Discussion

Our results revealed no quantitative differences between the

dominant and non-dominant wrist recordings. For both sites the
overall diurnal motor activity level and the diurnal motor activity
pattern were similar. We also found no quantitative differences for
these recording sites with regard to handedness. It should be noted
that this also illustrates an important limitation of motor activity
monitoring, in that the quality of movement of both wrists cannot be
addressed. McPartland et al. (1975) remarked that measurements of
motor activity of the non-dominant arm reflect total body movement
better because the dominant arm is more involved in performing

specific tasks. However, this issue was never appropriately addressed.

Although the majority of studies probably choose the non-dominant
wrist because of convenience, our results show that this recording
site quantifies motor activity to the same extent as the dominant
wrist.
As is to be expected, the amount of diurnal truncal motor activity
is significantly lower than that measured at both wrists. However,
comparisons between truncal and wrist motor activity should be
made with caution. First, the most sensitive axis of the waist monitor
maintains the same position during the recording, but that of the
wrist monitors changes accordingly to the position of the arm.
Second, the relation between the amount of motor activity measured
at both recording sites varies across the diurnal periods (Fig. 1).
Although not addressed in this study, this is also likely to be
influenced by lifestyle differences and type of employment. Hence, it
would be inaccurate to regard wrist motor activity measurements as
representative of an invariable amount of truncal motor activity.
During the nocturnal period the non-dominant wrist monitor
measured slightly more motor activity than the dominant wrist monitor, but the difference failed to be significant. This confirms the
results of Webster et al. (1982). Both wrist recordings detected more
motor activity (AL) than the waist recording. On the other hand, the
movement index showed no significant difference between the different recording sites. This finding is most likely explained by the
different characteristics of each measure. The movement index reflects the proportion of motor activity and immobility over time,
whereas the activity level reflects the level of motor activity per 15
sec. As can be observed from Fig. 3, during the nocturnal period
bilateral wrist motor activity occurred frequently in absence of truncal motor activity. The reverse combination, however, is exceedingly
exceptional. Thus integrated generalized movements like postural
shifts are measured at all recording sites, but the small movements
that may occur at the distal extremities are predominantly recorded
by wrist-worn monitors.
In conclusion, from our results it is apparent that for both diurnal
and nocturnal studies on the assessment of motor activity, either
wrist can be chosen as the recording site. However, because our
results are derived from 20 subjects this conclusion will have to be
verified in a larger sample of subjects. Across the diurnal period the
relation between motor activity recorded at the wrist and waist is
subject to considerable variability. During the nocturnal period motor activity can best be recorded at the wrist because this recording
site detects both integrated generalized movements and movements
that occur at the distal extremities.

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