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VOLUME 7, ISSUE 1 

 2024 
 

RESEARCH ARTICLE 

 

Sonune S.P, Saha A, Joshi N.G, Pathak S, Bhadra P, Goel G. The effect of a modified tenodesis wrist-hand orthosis on hand function in patients with tetraplegia. 
Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.8. https://doi.org/10.33137/cpoj.v7i1.42879   

 

https://jps.library.utoronto.ca/index.php/cpoj/index
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https://doi.org/10.33137/cpoj.v7i1.42879


 

1 

Sonune S.P, Saha A, Joshi N.G, Pathak S, Bhadra P, Goel G. The effect of a modified tenodesis wrist-hand orthosis on hand function in patients with tetraplegia. 
Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.8. https://doi.org/10.33137/cpoj.v7i1.42879 

 

 

RESEARCH ARTICLE 

 

THE EFFECT OF A MODIFIED TENODESIS WRIST-HAND ORTHOSIS ON HAND FUNCTION 

IN PATIENTS WITH TETRAPLEGIA 

Sonune S.P, Saha A*, Joshi N.G, Pathak S, Bhadra P, Goel G 

Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Bhopal, India. 
 
 
  
 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

INTRODUCTION   

Spinal cord injury (SCI) is a complicated and incapacitating 

disorder that often leads to significant functional loss. India 

reports approximately 20,000 new cases of spinal cord 

injury (SCI) each year, with a majority affecting young   

individuals from lower socioeconomic backgrounds.1  

 

 

 

 

 

The prevalence of traumatic cervical spine fractures in 

Western populations ranges from 4 to 17 cases per 100,000 

person-years, with concurrent cervical spinal cord injuries 

(SCI) occurring in 10–11% of cases.2 Loss of hand function 

is one of the most notable areas of impairment for people 

with cervical SCI, and it significantly affects their everyday 

activities and quality of life. The upper limb function, 

particularly hand grasp and release, is critical for performing 

essential tasks of daily living, social interaction, and 

vocational activities. Consequently, restoring hand function 

is a primary objective following cervical spinal cord injury 

(SCI). A study by Anderson involving 347 individuals with 

 
OPEN  ACCESS 

ABSTRACT 

BACKGROUND: An individual experiencing tetraplegia faces functional limitations due to impaired hand 

function. The use of an affordable tenodesis wrist-hand orthosis (WHO) can enable finger flexion with active 

wrist extension, thereby enhancing the three-jaw chuck grasp and overall hand functionality. 

OBJECTIVES: To assess hand function and satisfaction in patients with tetraplegia using a modified 

tenodesis wrist-hand orthosis (WHO), utilizing the Duruöz Hand Index (DHI) and the Orthotics and 

Prosthetics User Survey (OPUS) satisfaction with device and services subscales. 

METHODOLOGY: The study was conducted at a tertiary care center in central India, enrolling patients with 

tetraplegia admitted to the Department of Physical Medicine and Rehabilitation. A modified tenodesis wrist-

hand orthosis (WHO) was designed using low-temperature thermoplastic components. Twenty-two 

individuals with a minimum wrist extensor power of grade 3/5 were included in the study. These patients 

were provided with the modified tenodesis WHO and underwent daily training sessions for a period of 2 

weeks. Duruöz Hand Index (DHI) scores were assessed at baseline, 6 weeks, and 12 weeks post-

enrolment. Patient satisfaction was evaluated using the Orthotics and Prosthetics User’s Survey (OPUS) 

satisfaction with device and services subscales.  

FINDINGS: The analysis of the DHI scores indicated a significant enhancement in functional abilities at 

both 6-week and 12-week follow-ups compared to the baseline assessment. Notably, the most substantial 

progress at 6 weeks follow-up was observed in tasks such as buttoning a shirt, while significant 

improvement at the 12-week mark was noted in activities like turning a key in a lock. The median OPUS 

device satisfaction score was 50, corresponding to a Rasch score of 68.8. Additionally, the median OPUS 

satisfaction score for services stood at 46, with a Rasch score of 72.7. Patients expressed the highest 

satisfaction levels with the courteous demeanor of the staff, prompt scheduling of appointments, and 

accurate fitting of the orthosis. 

CONCLUSION: The study findings indicate that the modified tenodesis WHO is an effective and 

satisfactory therapeutic device for improving hand function in patients with tetraplegia. The findings 

encourage further investigation and application of the modified tenodesis WHO in clinical practice. 

ARTICLE INFO 

Received: March 10, 2024 

Accepted: October 18, 2024 

Published: October 28, 2024 
 

CITATION 

Sonune S.P, Saha A, Joshi N.G, 

Pathak S, Bhadra P, Goel G. The 

effect of a modified tenodesis wrist-

hand orthosis on hand function in 

patients with tetraplegia. Canadian 

Prosthetics & Orthotics Journal. 

2024; Volume 7, Issue 1, No.8. 

https://doi.org/10.33137/cpoj.v7i1.

42879 

KEYWORDS 

Hand Orthosis, Wrist Hand 

Orthosis, Spinal Cord Injury, 

Tetraplegia, Hand Rehabilitation, 

Orthosis 

 
 

* CORRESPONDING AUTHOR: 

Dr. Anyesha Saha, 

Affiliation: Department of Physical Medicine and Rehabilitation, All India 
Institute of Medical Sciences, Saket Nagar, Bhopal (M.P.), India. 

E-Mails: saha.anyesha@gmail.com; anyesha.sr2023@aiimsbhopal.edu.in 

ORCID ID: https://orcid.org/0009-0004-1574-0519 
 

 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

Volume 7, Issue 1, Article No.8. 2024 

 

 

https://doi.org/10.33137/cpoj.v7i1.42879
https://doi.org/10.33137/cpoj.v7i1.42879
https://doi.org/10.33137/cpoj.v7i1.42879
mailto:saha.anyesha@gmail.com
mailto:anyesha.sr2023@aiimsbhopal.edu.in
https://orcid.org/0009-0004-1574-0519
https://jps.library.utoronto.ca/index.php/cpoj/index


 

2 

Sonune S.P, Saha A, Joshi N.G, Pathak S, Bhadra P, Goel G. The effect of a modified tenodesis wrist-hand orthosis on hand function in patients with tetraplegia. 
Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.8. https://doi.org/10.33137/cpoj.v7i1.42879 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X MODIFIED TENODESIS ORTHOSIS AND HAND FUNCTION IN PATIENTS WITH TETRAPLEGIA 

Sonune et al., 2024 

cervical-level SCI found that 48.7% of patients prioritized 

regaining arm and hand function as the most impactful 

improvement for their quality of life, ranking it above sexual 

function, trunk stability, bowel and bladder control, and 

walking.3 Despite advancements in medical management 

and rehabilitation, many individuals with SCI still face 

significant challenges in regaining optimal hand function. 

Tenodesis grasp and release is a biomechanical 

phenomenon that occurs with wrist extension and flexion 

and plays a crucial role in enabling functional grasp and 

release movements in individuals with SCI. The tenodesis 

effect is used in patients with tetraplegia with innervated 

wrist extensor muscles but paralyzed finger and thumb 

flexor muscles. When the wrist is actively extended, passive 

tension of the extrinsic flexors of the thumb and fingers 

creates a grasp pattern between the thumb and fingers, 

resulting in a lateral pinch.4  

Active flexion of the wrist causes passive extension of the 

fingers. As the flexor digitorum profundus and superficialis 

are polyarticular muscles, complete extension of the wrist 

leads to about 20 degrees of flexion at the distal inter-

phalangeal (DIP) joints, 50 degrees of flexion at the 

proximal inter-phalangeal (PIP) joints and 35 degrees of 

flexion at the metacarpophalangeal (MCP) joints in healthy 

individuals. Gravity can be used to flex the wrist, which 

stretches the finger and thumb extensors and thus causes 

the hand to open. When the wrist is actively extended, 

passive stretch in the flexor digitorum profundus (FDP) and 

superficialis and flexor pollicis longus (FPL) effectively 

flexes the finger and thumb.5 The wrist extension torque 

(T1) produced by active wrist extension, leads to the 

development of a counter-clockwise torque at the MCP 

joints (T2). This torque at the MCP joints is balanced with 

the three-jaw chuck force (F) at the static pinch between the 

first 3 digits (Figure 1).6 

However, disruptions in tenodesis often result from altered 

muscle balance due to neurological deficits. This can lead 

to an inability to grasp objects effectively, diminishing a 

patient's autonomy and independence. To address this 

issue, orthoses have been explored to facilitate tenodesis 

grasp and improve hand function. The strength of the grasp 

depends on the amount of wrist extensor torque. A 

tenodesis wrist hand orthosis utilizes the natural tenodesis 

grasp as well as enhances this grasp by pulling the fingers 

towards the thumb using a connecting lever arm.7  

The tenodesis wrist hand orthosis is a dynamic WHO that 

aims to enhance hand function by utilizing the natural 

mechanical advantage provided by intact wrist extensor 

muscles. The conventional tenodesis orthosis, also known 

as the flexor-hinge orthosis (FHO), was made of metal. The 

plastic tenodesis WHO developed at Rehabilitation Institute 

of Chicago (RIC) was a modification of traditional high 

temperature thermoplastic WHO developed in 1960.7 

While metals have been used in orthoses for many 

decades, the use of plastics in orthoses has now become 

more prevalent. Plastics can be divided into two categories: 

thermoplastic and thermosetting. The modified tenodesis 

wrist hand orthosis used in this study is made of low-

temperature thermoplastic that becomes malleable at a 

temperature of less than 149 °C. Unlike the high 

temperature thermoplastic RIC tenodesis WHO, a negative 

cast is not required in fabricating this orthosis.8,9 Thus, the 

fabrication of this modified tenodesis WHO requires less 

time and can be easily remoulded.  

Traditional tenodesis WHOs have shown promising benefits 

in helping people with SCI to perform grasp and release 

movements. However, modifications to the design and 

materials of the orthosis could enhance its effectiveness. 

These adjustments should consider factors such as 

comfort, flexibility, affordability, and the specific needs of 

each patient. Some variations include ratchet-driven 

FHOs,10 carbon dioxide-powered FHOs,11 electric motor-

driven FHOs, and cable-operated FHOs.12 Some 

modifications of FHO for individuals with higher-level SCI 

who lack voluntary wrist extension and have poor hand 

function include the ratchet FHO, McKibben FHO, electric 

motor-driven FHO, and shoulder harness-driven FHO.6 

Recent advancements in WHOs for patients with tetraplegia 

have led to improved functionality and usability. The 

Sequential Advancing Flexion Retention Attachment 

(SAFRA) was developed for patients with tetraplegia with a 

muscle power of 2/5 or 3/5 in the wrist extensors. The 

SAFRA was integrated into a standard wrist-driven flexor 

hinge WHO with an adjustable tenodesis bar, eliminating 

the need for externally powered devices to achieve 

prehension.13 In South Korea, a novel 3D-printed hand 

orthosis controlled by electromyography (EMG) signals was 

tested on 10 patients, showing improvements in hand 

function.14  Wearable robotic hand exoskeletons and gloves 

have also been developed for patients with tetraplegia.15,16 

However, most of these modified WHOs were bulky and 

patients encountered issues with donning them. 

In the Indian setting, there is a need for a more affordable 

and comfortable alternative to the tenodesis WHO that 

should be easy to manufacture. The use of thermoplastic 

materials that become pliable when heated can expedite the 

production of the orthosis, thereby reducing overall costs. 

We developed a modified form of tenodesis WHO in 

response to these demands. This observational study was 

aimed at determining how this alteration affects manual 

ability among people suffering from SCI.  

 

https://doi.org/10.33137/cpoj.v7i1.42879


 

3 

Sonune S.P, Saha A, Joshi N.G, Pathak S, Bhadra P, Goel G. The effect of a modified tenodesis wrist-hand orthosis on hand function in patients with tetraplegia. 
Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.8. https://doi.org/10.33137/cpoj.v7i1.42879 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X MODIFIED TENODESIS ORTHOSIS AND HAND FUNCTION IN PATIENTS WITH TETRAPLEGIA 

Sonune et al., 2024 

Figure 1: Biomechanics of a tenodesis WHO. A: Flexion of the 

fingers with the extensor torque at the wrist; B: Extension of the 

fingers with the flexor torque at the wrist; C: Passive stretch of the 

finger flexors with active wrist extension. F: Three-jaw chuck force; 

FDP: Flexor digitorum profundus; FPL: Flexor pollicis longus; MCP: 

Metacarpophalangeal joint; T1: Wrist extension torque; T2: 

Metacarpophalangeal joint flexion torque; T3: Flexion torque at the 

wrist; T4: Extension torque at the MCP joint; W: Wrist joint. 

METHODOLOGY 

A prospective, single-arm observational study was 

conducted at a tertiary care center in central India to 

determine the effectiveness of a modified tenodesis wrist-

hand orthosis (WHO) and assess patient satisfaction 

among individuals with spinal cord injury (SCI). All patients 

with SCI admitted to the Physical Medicine and 

Rehabilitation department were assessed, and those 

meeting the inclusion criteria (Table 1) were enrolled in the 

study through convenience sampling. A total of 35 

individuals with SCI were screened by the primary 

investigator, of whom 22 patients were enrolled in the study. 

The study was approved by the institutional ethics 

committee (Institutional Human Ethics Committee, AIIMS 

Bhopal), and written informed consent was obtained from all 

participants before enrolment. 

The neurological level or completeness of the injury was not 

used as a criterion for inclusion or exclusion. The tenodesis 

action utilized by this modified tenodesis WHO requires 

active wrist extension. Therefore, individuals with at least 

grade 3/5 strength in their wrist extensors irrespective of 

injury level or completeness, were considered potential 

candidates. 

Each extremity of subjects was screened separately. If both 

sides lacked prehensile ability and had a power of 3/5 or 

more in wrist extensors, bilateral modified tenodesis WHO 

was prescribed. 

Table 1: Subject inclusion and exclusion criteria.  

INCLUSION CRITERIA EXCLUSION CRITERIA 

1) Spinal cord injury with 

wrist extensor power of at 

least 3/5* 

 

2) Non-prehensile† 

 

3) Flexible wrist, 

metacarpophalangeal, 

and interphalangeal 

joints‡ 

1) Impaired cognitive function 

2) Recent fracture 

3) Complex regional pain syndrome 

4) Neuropathy affecting the upper limb 

(ulnar /median/radial neuropathy or 

brachial plexopathy) 

5) Arthritis in the wrist and joints of the 

fingers 

6) Acute burn injury to the wrist and hand 

7) Grade 2, 3, or 4 spasticity in the wrist 

or finger flexors or extensors¶ 

 

* Power was graded based on the Medical Research Council17; 

† Non-prehensile was defined as the inability to seize or grasp an 

object, based on Napier’s18 classification; ‡ Full passive range of 

motion at the wrist with 70 degrees of extension and 80 degrees of 

flexion and at least 20 degrees of flexion at the DIP, 50 degrees of 

flexion at the PIP, and 35 degrees of flexion at the MCP joints;   ¶ 

spasticity was assessed by the modified Ashworth scale. 

For all patients, the modified tenodesis WHO was fabricated 

and fitted by an orthotist and prosthetist with 14 years of 

experience. 

A custom molded, comfortable, lightweight modified 

tenodesis WHO was designed using 2 mm low-temperature 

thermoplastic at a tertiary care rehabilitation center in 

central India, employing tenodesis grasp and biomechanical 

principles. 

 

Figure 2: Modified tenodesis wrist hand orthosis. The orthosis is 

made of low-temperature thermoplastic material and consists of 

four components. A: Dorsal finger plate for digits 2 and 3; B: An 

elastic lacer that serves as the wrist component and facilitates the 

translation of tenodesis; C: Distal palmar forearm component; D: 

Short opponens component. 

As illustrated in Figure 2, the modified tenodesis WHO is 

comprised of four components: segment (A) encompasses 

the middle and distal interphalangeal joints of the index and 

middle fingers; segment (B) is an elastic lacer that anchors 

 
 

T3 

T4 

W 
MCP 

T2 

T1 

W 

MCP 

Active wrist 

extensors 

A B 

C 

Taut FDP, FPL 

W 

F 

B 

C 

D 

A 

https://doi.org/10.33137/cpoj.v7i1.42879


 

4 

Sonune S.P, Saha A, Joshi N.G, Pathak S, Bhadra P, Goel G. The effect of a modified tenodesis wrist-hand orthosis on hand function in patients with tetraplegia. 
Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.8. https://doi.org/10.33137/cpoj.v7i1.42879 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X MODIFIED TENODESIS ORTHOSIS AND HAND FUNCTION IN PATIENTS WITH TETRAPLEGIA 

Sonune et al., 2024 

to the finger and forearm components, and facilitates 

translation of tenodesis; segment (C) encompasses the 

palmer wrist and forearm; and segment (D) a short 

opponens component, maintains the proximal palmer arc 

and aligns the thumb in opposition.  

Velcro® straps were used to secure the distal palmar 

forearm component, dorsal finger plate, and short opponens 

component, allowing adjustments for patient comfort. An 

elastic lacer, 2 mm thick, connected the volar surface of the 

dorsal finger plate to the volar surface of the distal palmar 

forearm component. The inclusion of the elastic lacer 

eliminated the need for actuating rod and artificial joint 

components as opposed to the conventional flexor hinge 

WHO, thus reducing the complexity of the orthosis.6 

The weight of this WHO was approximately 80 grams (75-

85 grams), slightly lighter than the conventional WHO 

(approximately 113 grams) and heavier than the RIC 

tenodesis WHO (42.5 grams).6 The orthosis was 

customized according to each individual’s shape and size, 

with a weight difference of 5-10 gram corresponding to the 

size variation. The cost of the orthosis is $4.50 USD, 

inclusive of material costs and labor charges, making it 

more economical than the RIC tenodesis WHO, priced at 

around $39.95 USD.19  

After applying the modified tenodesis WHO, participants 

were trained for 2 weeks regarding the proper usage of the 

orthosis, and specific task-oriented training was given to the 

patients. All participants required the help of the caregiver 

for donning and doffing. During this period, the 

accompanying family members/caregivers were also taught 

proper donning and doffing of the orthosis. Proper care of 

the orthosis, avoidance of heat, cleaning with cold water, 

the need for the orthosis and the mechanism of use of the 

orthosis were explained to the individual. The participants 

were allowed to ask their queries regarding the orthosis 

throughout the sessions. 

 

Figure 3: A patient with tetraplegia demonstrating use of the 

modified tenodesis WHO. A: Wrist flexion; B: Wrist extension and 

three-jaw chuck grasp; C: Holding a pen. 

All the study participants received intensive training for 45 

minutes per day for 2 weeks under a trained Occupational 

Therapist. The training included wrist extensor and flexor 

strengthening exercises, peg-socket activities, grasp and 

release activities (Figure 3), and activities of daily living 

(ADL) training in a simulated environment.    

The demographic and clinical data of the participants were 

documented. The outcome measures included the Duruöz 

Hand Index (DHI) and the Orthotics and Prosthetics User’s 

Survey (OPUS) satisfaction with device and services. The 

DHI is a valid tool for patients with tetraplegia, and it is used 

to assess hand function.20 The DHI is a Likert scale that 

comprises 18 questions pertaining to hand activities that 

can be assessed based on the patient’s perspective. The 

OPUS satisfaction with device and services subjectively 

measured satisfaction with the device and the services 

using a 21-item survey.21 

While assessing DHI, a few questions pertained to the use 

of a single hand, such as picking up a coin from the tabletop. 

These activities were assessed on the side on which the 

orthosis was prescribed. In those patients who were fitted 

with bilateral modified tenodesis WHO, the dominant hand 

was assessed for activities requiring a unilateral hand. The 

dominant hand was determined based on pre-injury hand 

dominance. Outcome measures were recorded without the 

orthosis initially (week 0) and with the orthosis at 6 weeks 

and 12 weeks by the same treating physician at each follow-

up. 

Statistical analysis 

Categorical variables such as gender, neurological level of 

injury (NLI), and the side of use for the modified tenodesis 

WHO were presented as counts and percentages. 

Continuous variables, including age and duration since 

injury, were expressed as means, standard deviations, and 

ranges. Mean values were taken for individual items of the 

OPUS satisfaction with device and services, while a median 

value was taken for the total OPUS satisfaction with device 

and services score to represent the central tendency, as it 

is a Likert type of scale. A Wilcoxon signed-rank test was 

employed to assess the change in mean DHI scores of all 

22 patients at 6 weeks and 12 weeks compared to baseline. 

Statistical significance was set at p < 0.05 and analysis was 

conducted using SPSS version 21.0. 

RESULTS 

Twenty-two individuals with tetraplegia were included in the 

study, of whom 18 were male and 4 were female. Eleven 

subjects were fit with the modified tenodesis WHO on the 

right upper extremity, whereas 6 subjects were fit with the 

device on the left upper extremity and 5 were fit with the 

device on both upper extremities (Table 2). 

 

A B

 

C

 

https://doi.org/10.33137/cpoj.v7i1.42879


 

5 

Sonune S.P, Saha A, Joshi N.G, Pathak S, Bhadra P, Goel G. The effect of a modified tenodesis wrist-hand orthosis on hand function in patients with tetraplegia. 
Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.8. https://doi.org/10.33137/cpoj.v7i1.42879 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X MODIFIED TENODESIS ORTHOSIS AND HAND FUNCTION IN PATIENTS WITH TETRAPLEGIA 

Sonune et al., 2024 

Table 2: Subjects demographic data. 

 

The DHI score at admission was collected as the baseline. 

The mean ± standard deviation for DHI at baseline (no 

orthosis) was 83.4 ± 3.72, while it was 75.5 ± 5.12 at 6 

weeks and 68.9 ± 6.92 at 12 weeks with the modified 

tenodesis WHO, respectively. Compared to the baseline, 

there was a significant improvement in DHI at 6 weeks 

(p<0.001) and 12 weeks (p<0.001) with the use of the 

modified tenodesis WHO (Figure 4). 

 

Figure 4: Duruoz Hand Index (DHI). *p<0.001 for difference in 

mean DHI scores at 0 and 6 weeks; ** p<0.001 for difference in 

mean DHI scores at 0 and 12 weeks. The total DHI score (out of 

90) was calculated for all 18 items, while each item was scored from 

0-5 (0: Yes, without difficulty; 1: Yes, with a little difficulty; 3: Yes, 

with much difficulty; 4: Nearly impossible to do; 5: Impossible). 

Among all the items on the DHI scale, the activity performed 

with the least difficulty while using the modified tenodesis 

WHO was pricking items with a fork. Significant 

improvement (Table 3) was perceived in performing all 

functional activities of the DHI scale using the modified 

tenodesis WHO at 12 weeks as compared to baseline 

except unscrewing the lid of a jar and peeling a fruit. The 

most significant functional improvement at 6 weeks 

compared to baseline was observed in buttoning a shirt 

(p=0.000), whereas the greatest enhancement was noted in 

turning a key in a lock at 12 weeks (p=0.000) compared to 

baseline (Table 3). 

The median for the OPUS device satisfaction score was 50, 

pertaining to a Rasch score of 68.8 and the median for the 

OPUS satisfaction for services score was 46, with a Rasch 

score of 72.7. Among the subitems of the OPUS device 

satisfaction, the maximum satisfaction was experienced 

with respect to the fit of the orthosis, while the least 

satisfaction was experienced with donning the orthosis 

(Figure 5A) 

All patients expressed the highest satisfaction with the 

behavior of staff (i.e., courteous and respectful) and 

expressed the lowest satisfaction with their own decision-

making process regarding the orthosis (Figure 5B). 

DISCUSSION 

The results of this prospective observational study 

demonstrated significant improvements in hand function 

among patients with SCI who utilized the modified tenodesis 

WHO. 

The effectiveness of this modified tenodesis WHO in 

enhancing hand function is demonstrated by a significant 

improvement in the DHI scores after 6 and 12 weeks 

compared to baseline. The notable enhancements in 

activities such as opening a lock and buttoning a shirt 

underscore the importance of the modified tenodesis 

orthosis in improving pinch grip. This orthosis enables 

skillful placement of objects between the thumb and fingers, 

facilitating the manipulation of small items like keys, forks, 

buttons, and pens, ultimately enhancing overall hand 

function. However, the omission of the digits 4 and 5 from 

the modified WHO may have contributed to limitations in 

spherical and cylindrical grasp as these types of grasp 

patterns typically require engagement of all five digits. Thus, 

there were limited gains in activities such as unscrewing a 

jar, holding a bowl, or lifting a bottle. Hence, a limitation of 

the orthosis is that it restricts grasping that requires all five 

digits, likely necessitating the user to employ alternative 

movements to compensate for this limitation. Similar results 

with improvements in hand function using various designs 

of a tenodesis WHO have been previously seen. In a study 

by Meyer et al., the application of a flexor hinge WHO 

enabled a 43-year-old teacher with a complete C6-level SCI 

to return to work and perform domestic activities, such as 

cooking.22 In the same study, another woman who had a C6-

Item Number Percentage (%) 

Gender 

Male 18 81.8 

Female 4 18.2 

*NLI: Neurological level of 
 injury 

C2 1 4.5 

C4 3 13.7 

C5 11 50.0 

C6 5 22.7 

C7 2 9.0 

Modified tenodesis WHO 
side 

Right 11 50.0 

Left 6 27.3 

Bilateral 5 22.7 

Dominant  12 54.6 

Non-dominant  5 22.7 

Dominant and non-
dominant  

5 22.7 

Mean age (range) 36.7 (20-64) years 

Mean duration since injury 
(range) 

9.8 (3-34) months 

Duruöz Hand Index 

Baseline (0 week) 6 weeks 12 weeks 

https://doi.org/10.33137/cpoj.v7i1.42879


 

6 

Sonune S.P, Saha A, Joshi N.G, Pathak S, Bhadra P, Goel G. The effect of a modified tenodesis wrist-hand orthosis on hand function in patients with tetraplegia. 
Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.8. https://doi.org/10.33137/cpoj.v7i1.42879 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X MODIFIED TENODESIS ORTHOSIS AND HAND FUNCTION IN PATIENTS WITH TETRAPLEGIA 

Sonune et al., 2024 

level complete lesion was able to return to the farm and 

perform activities like cooking, sewing, and knitting with 

bilateral flexor-hinge WHO. A modified wrist-driven flexor 

hinge WHO with a dial lock, allowing the orthosis to function 

at different ranges of motion at the wrist joint, was studied 

by Rout et al.23 They observed that without the orthosis, 

participants were able to lift 50 grams of weight, while with 

the orthosis, there was an increase in the ability to lift the 

weight up to 300 grams. In our study, significant 

improvement in the ability to raise a full bottle and plate full 

of food indicates an increased ability to lift weight, but the 

improvement in such activities at 6 weeks was not 

significant.  

In a study by Yoo et al. a 3D-printed myoelectric wrist hand 

orthosis was assessed for improvement in hand function of 

persons with SCI,14 representing one of the latest 

advancements for patients with tetraplegia. Their findings 

also demonstrated improvement in eating with the 3D-

printed orthosis, although there were no significant gains in 

dressing or grooming abilities.  

Batra et al. compared the efficacy of biofeedback to use of 

a tenodesis WHO in persons with C5-C6 SCI.24 A significant 

improvement in the ability to lift weights and in the 

Functional Independence Measure (FIM) was achieved in 

both the groups, but biofeedback was found to be more 

effective. Based on these promising findings, biofeedback 

could potentially be used in conjunction with the use of the 

modified tenodesis WHO in future studies to investigate its 

efficacy in facilitating clinical outcomes. 

Assessment using the OPUS satisfaction with device and 

services in our study revealed that participants expressed 

high satisfaction levels with the courteous behavior of staff, 

prompt appointment scheduling, and appropriate fit of the 

orthosis. The thermoplastic material's easy moldability 

directly over the skin ensured an appropriate fit, and 

patients reported satisfaction with training and ease of use. 

However, a notable area of dissatisfaction was experienced 

during the donning and doffing of the orthosis. Despite 

having fewer components compared to traditional flexor 

hinge orthosis, patients with impaired hand function often 

require assistance from caregivers due to weakness in both 

upper extremities, indicating a need for further modifications 

to improve independent donning and doffing capabilities. 

The results of this study hold significant clinical implications 

for patients with SCI undergoing hand function 

rehabilitation, potentially enhancing their participation in 

both personal and professional activities. 

Furthermore, investigating the long-term effects of the 

modified tenodesis WHO on hand function and exploring its 

applicability across various levels and severities of SCI are 

avenues for further research. Additionally, incorporating 

qualitative measures to capture participants’ perceptions 

and experiences with the WHO could provide valuable 

insights into its acceptability and usability. 

 

Table 3: Mean and standard deviation (SD) of each DHI subitem at 6 weeks and 12 weeks as compared to the baseline. 

 
DHI mean ± SD at 

0 week 
DHI mean ± SD at 

6 weeks 
DHI mean ± SD at 

12 weeks 
p*  p** 

Hold a bowl 4.72 ± 0.63 4.64 ± 0.66 4.23 ± 0.92 0.157 0.009 

Seize a full bottle and raise it 4.90 ± 0.29 4.77 ± 0.43 4.32 ± 0.72 0.083 0.004 

 Hold a plate full of food 4.72 ± 0.55 4.59 ± 0.59 4.14 ± 0.89 0.083 0.006 

Pour liquid from a bottle into a glass 4.86 ± 0.35 4.68 ± 0.65 4.32 ± 0.78 0.102 0.006 

Unscrew the lid from a jar opened before 4.72 ± 0.70 4.68 ± 0.72 4.59 ± 0.80 0.317 0.180 

Cut meat with a knife 4.40 ± 0.91 3.55 ± 0.60 3.41 ± 0.67 0.000 0.000 

Prick things well with a fork 3.77 ± 0.81 2.73 ± 0.46 2.45 ± 0.51 0.002 0.000 

Peel fruit 4.90 ± 0.29 4.91 ± 0.29 4.68 ± 0.57 1.000 0.059 

Button your shirt 4.50 ± 0.86 3.32 ± 0.89 3.05 ± 0.95 0.000 0.000 

Open and close a zipper 4.27 ± 0.83 3.86 ± 0.94 3.59 ± 0.67 0.003 0.000 

Squeeze a new tube of toothpaste 4.50 ± 0.86 3.95 ± 0.90 3.64 ± 0.66 0.006 0.000 

Hold a toothbrush efficiently 4.72 ± 0.46 4.36 ± 0.79 3.32 ± 0.84 0.023 0.000 

Write a short sentence with a pencil or ordinary 
pen 

4.54 ± 0.67 3.86 ± 0.83 3.27 ± 0.83 0.004 0.000 

Write a letter with a pencil or ordinary pen 4.90 ± 0.29 4.32 ± 0.84 3.77 ± 0.81 0.009 0.000 

Turn around doorknob 4.72 ± 0.63 4.68 ± 0.72 4.41 ± 0.80 0.317 0.020 

Cut a piece of paper with scissors 4.90 ± 0.43 4.86 ± 0.47 4.73 ± 0.55 0.317 0.046 

Pick up coins from a tabletop 4.31 ± 0.84 3.95 ± 0.95 3.59 ± 0.73 0.011 0.000 

Turn a key in a lock 4.90 ± 0.29 3.82 ± 0.59 3.36 ± 0.49 0.000 0.000 
 

p* = p-value between means at 0 and 6 weeks. p**= p value between means at 0 and 12 weeks. The p-values are calculated using the 

Wilcoxon signed-rank test. 

 

https://doi.org/10.33137/cpoj.v7i1.42879


 

7 

Sonune S.P, Saha A, Joshi N.G, Pathak S, Bhadra P, Goel G. The effect of a modified tenodesis wrist-hand orthosis on hand function in patients with tetraplegia. 
Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.8. https://doi.org/10.33137/cpoj.v7i1.42879 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X MODIFIED TENODESIS ORTHOSIS AND HAND FUNCTION IN PATIENTS WITH TETRAPLEGIA 

Sonune et al., 2024 

Limitations 

Several limitations warrant consideration. The lack of a 

control group precludes definitive causal conclusions 

regarding the efficacy of this wrist hand orthosis. 

Additionally, the relatively short intervention period may 

have influenced the magnitude of the observed 

improvements. Future studies could mitigate these 

limitations by incorporating randomized controlled designs 

and extended intervention durations. 

CONCLUSION 

In conclusion, the results of this observational study 

provided evidence supporting the potential efficacy of a 

modified tenodesis WHO in improving hand function among 

patients with SCI, particularly in activities such as eating 

with a fork, buttoning a shirt, locking with a key, holding a 

toothbrush, and writing with a pen. The observed 

enhancements in functional independence suggest that this 

intervention could significantly contribute to hand 

rehabilitation strategies for individuals with SCI. The 

participants had maximum satisfaction with the behavior of 

the staff, prompt appointments and appropriate fit of the 

device, while they were most concerned with donning 

difficulty. The findings encourage further investigation and 

application of the modified tenodesis WHO in clinical 

practice. 

ACKNOWLEDGEMENTS 

The authors would like to express their gratitude to the study 

participants, whose enthusiastic involvement made this work 

possible. 

DECLARATION OF CONFLICTING INTERESTS 

 The authors disclose that they have no personal or financial ties to 

any companies or people that could have impacted their research. 

 

AUTHORS CONTRIBUTION 

• Swapnil P. Sonune: Conceptualization, Original drafting, 

Writing, Data collection, Statistical analysis. 

• Anyesha Saha: Writing, Data collection, Statistical analysis, 

Revising the manuscript. 

• Joshi Niravkumar Ganpatram: Writing, Data collection, 

Revising the manuscript. 

• Smita Pathak: Designing orthosis. 

• Prasenjit Bhadra: Writing, Data collection, Revising the 

manuscript. 

 

Figure 5: OPUS satisfaction scores. A: Satisfaction for device; B: Satisfaction for services. The response to each item was scored as follows: 

5= Strongly agree; 4= Agree; 3= Neither; agree nor disagree; 2= Disagree; 1= Strongly disagree. 

0 1 2 3 4 5 6

My prosthesis/orthosis fits well

The weight of my prosthesis/orthosis is managable

My prosthesis/orthosis is comfortable throughout the day

It is easy to put on my prosthesis/orthosis

My prosthesis/orthosis looks good

My prosthesis/orthosis is durable

My clothes are free of wear and tear from my prosthesis/orthosis

My skin is free of abrasions and irritations

My prosthesis/orthosis is pain free to wear

I can afford the out-of-pocket expenses to purchase and maintainmy prosthesis /orthosis

I can afford to repair or replace my prosthesis/ orthosis as soon as needed

Mean score

Mean score of subitems of OPUS satisfaction for device 

0 1 2 3 4 5 6

I received an appointment with a prosthetist/orthotist within a reasonable amount of time

I was shown the proper level of courtesy and respect by the staff

I waited a reasonable amount of time to be seen

Clinic staff fully informed me about the equipment choices

The prosthetist/orthotist gave me the opportunity to express my concerns regarding the equipment

The prosthetist/orthotist was responsive to my concerns and questions

I am satisfied with the training I received in the use and maintenance of my prosthesis/ orthosis

The prosthetist / orthotist discussed problems I might encounter with the equipment

The staff coordinated their services with my therapists and doctors

I was a partner in decision making with clinic staff regarding my care and equipment

Mean score

Mean score of subitems of OPUS satisfaction for services

A 

B 

https://doi.org/10.33137/cpoj.v7i1.42879


 

8 

Sonune S.P, Saha A, Joshi N.G, Pathak S, Bhadra P, Goel G. The effect of a modified tenodesis wrist-hand orthosis on hand function in patients with tetraplegia. 
Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.8. https://doi.org/10.33137/cpoj.v7i1.42879 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X MODIFIED TENODESIS ORTHOSIS AND HAND FUNCTION IN PATIENTS WITH TETRAPLEGIA 

Sonune et al., 2024 

• Gaurav Goel: Writing, Data collection, Revising the   

manuscript. 

All authors reviewed the manuscript and approved the final version. 

 

SOURCES OF SUPPORT 

There was no funding for this research. 

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https://www.oandplibrary.org/op/1965_02_137.asp
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https://aiota.org/temp/ijotpdf/ibat08i3p75.pdf

