Adapted Sports and Equipment

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Author: Sharon Jang | Reviewer: Courtney Pollock | Published: 18 October 2023 | Updated: ~

Key Points

  • Staying active after SCI has many benefits, but structured workouts may not be for everyone. Sports may be a good alternative to stay physically active.
  • Adapted sports (sometimes called “adaptive sports”) are sports that use modified equipment to allow individuals of all abilities to participate.
  • Participating in adapted sports is a great way to build social connections with others and to become a part of a community.
  • There are a variety of sports that can be played including cycling, court sports, winter sports, and water sports. This article introduces various adapted sports and the required equipment to partake in them.

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Staying physically active after SCI is important for your health. There is moderate to strong evidence that physical activity has many benefits after SCI including:

  • Allowing you to perform everyday activities (e.g., shopping, cooking, transferring) with more ease,
  • Improving depression and quality of life,
  • Increasing muscle strength and endurance,
  • Management of blood sugar levels,
  • Helping you to breathe with more ease,
  • Reducing pain and spasticity.

Although going to a gym is one common way to get moving, there are a variety of adapted sports that can also be played. While this article discusses a selection of adapted sports (including handcycling, court sports, winter sports, and water sports), it should be noted that almost any sport can be adapted for participation after SCI.

Refer to our article on Physical Activity for more information!

Adapted sports are sports that can be played with equipment and approaches that are adapted to a person’s physical abilities. Many adapted sports have been altered in one of many ways to promote accessibility. Some of these adaptations include changes to the rules of a game, modifications in the equipment, or specialized equipment to allow you to partake in a sport.

Athlete Classification

There are different levels of adapted sports, ranging from recreational (or just for fun and fitness) to competition. Should you want to become competitive, classifications are used to ensure that competition is equal and fair. Classifications are used to determine which athletes should be grouped together. In adapted sports, classification is based on function (e.g., strength, how many limbs are affected by injury, range of movement, tone/spasticity). This is similar to categorizing by age, gender, or weight in able-bodied sports.

Precautions when trying new sports

While trying out new sports can be fun and exciting, skin health is an important consideration. Trialing new sports is often associated with trying new equipment. When trying new equipment, it is important to check for red marks or pressure spots on your skin including your seat and any area of the body positioned against equipment (e.g., footrest or frame). People will commonly use the cushion from their everyday chair in their sport chair when they first try a sport. However, it is important to remember that although it is the same cushion, you may be sitting in a different position (e.g., seat angle) which will change pressure and potential forces from rubbing. The best approach is like that of trialing a new wheelchair or cushion: frequently check your skin in the early days of your new sport. This means that it is best to start with shorter sessions and work your way up in time once you know that your skin can tolerate the new equipment and positions. In water sports such as kayaking, or in rainy conditions for outdoor sports, make sure to check your skin when you are done since being wet can make the skin more prone to injury.

Additionally, you may want to consider the influence of temperature (extreme hot or cold weather), as temperature regulation may be impaired with an SCI.

Refer to our article on Pressure Injuries for more information!

Handcycles are a type of bicycle that is propelled by the arms instead of the legs. There are different types of handcycles available for all levels of ability. In general, most arm-cycles have alternative handle options for those with limited hand function.

Types of arm cycles

Recumbent cycles

Recumbent arm-cycles are three wheeled bikes that are controlled with the arms while seated in a reclined position. This type of bicycle has support straps to rest the feet in while cycling.

Upright cycles

Upright cycles are similar to recumbent bikes in that the feet are on either side of the front wheel. However, the user is seated in a more upright position when using this bike.

Tandem bikes

A variety of tandem arm bikes are available. Bike models are available to allow riders to either ride beside each other, or one in front of the other. Power-assist versions are also available for those who may have some function in their legs.

Arm cycle add-ons

Instead of buying a separate wheelchair, arm-cycle add-ons are available for manual wheelchair users. These add-ons connect to the front of a manual wheelchair, lifting up the casters. This then allows an individual to propel their wheelchair via an arm cycle. Additionally, power-assist versions are available for those with less upper body strength.

Off-road wheelchairs

If you are looking to go on some trails, an off-road wheelchair may appeal to you. These wheelchairs are used for recreational riding, such as going for a hike, or going fishing. Off-road wheelchairs often have larger, knobbier tires that are meant to withstand the trail, roots, and rocks. Like the arm-cycles, off-road wheelchairs come in a variety of set ups. Some setups may look like a typical manual wheelchair, but with larger wheels. There are also ones that are controlled with push-levers (such as the mountain trike), and powered wheelchairs with more power, suspension, and agility (such as the x5 frontier, and the x8-extreme all-terrain wheelchair).

Wheelchair racing

For those who are interested in competition, wheelchair racing may be an option. Wheelchair race events range from the 100m, 200m, 400m, 800m, 1500m, and 5k distance races in track and field, to marathons. Racing wheelchairs differ from the wheelchairs and cycles listed above in that they typically have two wheels with a third one extended out in front. Ideally, race chairs should be light-weight to enhance performance. When seated, the wheelchair should fit “like a glove”, and there should be little movement in the seat. Unlike arm-cycles, the feet are bent down and kept closer to the body. In addition, specialized rubber gloves are worn to push the rims during races.

Refer to our article on Wheelchair Propulsion Assist Devices for more information!


Wheelchair tennis is played on the same court as able-bodied tennis, and with similar rules. One rule difference is that in wheelchair tennis, players are allowed two bounces instead of one, and the second bounce can be anywhere – even out of bounds. Although one can play wheelchair tennis in their day chair, tennis wheelchairs are often preferred during play. These wheelchairs are faster, lighter, more agile, and more stable. The wheels on the wheelchair are also angled (i.e., there is more camber ) to allow for more swift turning. For those with limited hand function, taping the racquet to your hand is common practice, though it can take some time to find the optimal tension for you. Therefore, people with all levels of ability can play wheelchair tennis.


Wheelchair basketball is played on a standard basketball court. The wheelchair used for basketball is one with wheels angled to 15-20 degrees and a single rollerblade used for a caster at the back. In addition, there are many strapping options to promote stability and safety, or to hold the body in a certain position. Commonly strapped body parts include the hips, knees, feet and/or ankles. It is common for wheelchair basketball leagues to include able bodied participants at the local level of competition. This allows for more players and teams for great league play.


Wheelchair rugby was developed specifically for people with tetraplegia and has grown to include people without SCI but with similar functional abilities (e.g., some impaired arm and hand function in addition to impaired leg function). Wheelchair rugby is played with a volleyball. The goal of the game is to carry the ball over the other team’s goal line. Unlike able-bodied rugby, wheelchair rugby is played indoors on a court. Specialized wheelchairs are used to play wheelchair rugby and can be separated into chairs for offensive players and chairs for defensive players. Offensive wheelchairs are set up for speed and mobility and are distinguished with a front bumper to prevent other chairs from hooking them. Often, offensive chairs are used by players with more function. On the other hand, defensive wheelchairs are set up with a bumper to hook and hold onto other players. Defensive chairs are often used by players with less function. Additional equipment used in rugby include straps and gloves. Straps are used on the waist (to compensate for a lack of core muscles), the thighs (to prevent them from falling to the side or from shifting side to side), and the feet (for comfort). Meanwhile, gloves work to protect the skin, add extra grip when pushing the chair, and to making throwing and catching the ball easier.

Community Voices: Byron

Byron has been playing wheelchair rugby for 17 years. He describes it as “a fast-paced sport. You get to hit things with your wheelchair, and at the same time there is a lot of strategy going on.” He enjoys the sport as he explains, “the physical benefits are a big part of why I enjoy playing wheelchair rugby. The community is amazing – it’s great because every practice is an opportunity to see a bunch of my friends.”

Alpine Skiing

Alpine skiing, also known as downhill skiing, is a sport that individuals with tetraplegia and paraplegia can partake in with the use of sit-skis. In general, sit skis have a bucket-type of seat with an adjustable seat and footrest. To create a smoother ride, sit-skis have additional features such as suspensions and a shock compression system under the seat. The seat and suspension/shock systems are all connected to either a single ski (mono-ski) or a pair of skis (bi-skis). In general, mono-skis require the user to have good upper body strength, and the ability to ski independently. Bi-skis are often used by individuals who may require some assistance. Often, bi-skis are used with an able-bodied individual who skis behind them. Skiers who use a sit-ski can use the typical chairlifts at the mountains and with experience, can access all terrains of ski areas.

Cross Country Skiing

Cross country skiing (which is a type of Nordic skiing) allows individuals with paraplegia and tetraplegia to explore snowy trails. Like the alpine skis, cross country skis consist of a bucket seat that connects to a metal frame, which clips into the skis. Cross country skiers also often use poles while skiing to propel themselves along flatter terrain. If assistance is required, an able-bodied person can help push the ski forward with their ski-pole using an adaptive add-on.

Sledge (Ice) Hockey

Sledge hockey, or para ice hockey is identical to ice hockey but is played while sitting in sledges as opposed to standing on skates.

A sledge consists of a plastic bucket-shaped seat that is connected to a metal frame. This frame is set on two adjustable skate blades, with the blades aligned on the bottom of the seat. The skate blades may be adjusted so that they are further apart for stability (good for new players) or can be moved closer together to allow for more maneuverability and speed. Straps are available to help keep the feet, knees, and hips in place. Players propel themselves in the sledge using two sticks. These sticks are dual ended: one end has a blade for handling the puck, while the other end has a metal pick in it to help players propel themselves across the ice. Typical hockey pads are used for safety during play.


Adapted sailing is a sport that people of all abilities can participate in. Common features of adapted sailboats include handguards along the side of the boats, greater deck space due to removed masts, and customized molded seats with back support and belts that pivot. For individuals with reduced function, other available adaptations include electronic controls (such as the use of a joystick), and sip ‘n’ puff technology to steer the boat with breath. Many sailing clubs have power/mechanical lifts dockside to assist with transfers into boats.

Community Voices: Terry

Terry has been involved in adapted sailing since 1994. Terry sails a Matin 16 using sip ‘n puff technology. Sailing is special to Terry as he says he can “finally get out of my chair and be as free as the wind!” As he is unable to play court sports, sailing has provided Terry a competitive outlet.


Kayaks are available for people with all levels of SCI. While individuals with a lower level of injury may use non-adapted kayaks, adaptations are available for comfort and to accommodate those with limited function. Some kayaks may have custom seating with side and abdominal support. These supports are cushioned to protect the skin while kayaking. Stabilizing outriggers are available to increase stability of the boat and to reduce the chances of tipping. For those with limited arm/hand function, there are various adaptations for the paddle including:

  • A back of the hand grip, which places more paddling pressure on the arms instead of the hands.
  • Wrist cuff adaptation, which allows individuals to connect the paddle to their wrists via a cuff.

There are many benefits to staying physically active after SCI and there is a large variety of sports to participate in. Whether you prefer staying on land, floating on water, or being in the snow, most sports have been adapted in some way or another so that all who want to can participate! Prior to trying a sport, talk with your health providers to ensure that you are in a condition to play.

Evidence for “Why be physically active after SCI” is based on:

Martin KA, Latimer AE, Francoeur C, Hanley H. Sustaining exercise motivation and participation among people with spinal cord injuries – Lessons learned from a 9 month intervention. Palaestra 2002;18(1):38-51.

Hicks AL, Martin KA, Ditor DS, Latimer AE, Craven C, Bugaresti J et al. Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being. Spinal Cord 2003;41(1):34-43.

Latimer AE, Ginis KA, Hicks AL, McCartney N. An examination of the mechanisms of exercise- induced change in psychological well-being among people with spinal cord injury. J Rehabil Res Dev 2004;41(5):643-652.

Martin Ginis KA, Latimer AE, McKechnie K, Ditor DS, Hicks AL, Bugaresti J. Using exercise to enhance subjective well-being among people with spinal cord injury: The mediating influences of stress and pain. REHABIL PSYCHOL 2003;48(3):157-164.

Latimer AE, Martin Ginis KA, Hicks AL. Buffering the effects of stress on well-being among individuals with spinal cord injury: A potential role for exercise. Therapeutic Recreation Journal 2005;39(2):131-138.

Mulroy, S. J., Thompson, L., Kemp, B., Hatchett, P. P., Newsam, C. J., Lupold, D. G., et al. (2011). Strengthening and Optimal Movements for Painful Shoulders (STOMPS) in chronic spinal cord injury: a randomized controlled trial. Physical Therapy, 91, 305—324.

Jacobs, P. L. (2009). Effects of resistance and endurance training in persons with paraplegia. Medicine & Science in Sports & Exercise, 41, 992-997.

De Groot PC, Hjeltnes N, Heijboer AC, Stal W, Birkeland K. Effect of training intensity on physical capacity, lipid profile and insulin sensitivity in early rehabilitation of spinal cord injured individuals. Spinal Cord 2003;41(12):673-679.

de Carvalho DC, Martins CL, Cardoso SD, Cliquet A. Improvement of metabolic and cardiorespiratory responses through treadmill gait training with neuromuscular electrical stimulation in quadriplegic subjects. Artif Organs 2006;30(1):56-63.

Information for “What are adapted sports” is based on:

World Para Athletes. (n.d.). What is classification?

Information for “What types of cycling and pushing sports are there?” is based on:

World Para Athletes. (n.d.). Para-athletics explained: Wheelchair racing.

Chair Institute. (2019). Best off road all terrain wheelchairs for outdoors review 2020.

Information for “What adapted court sports are available?” is based on:

BC Wheelchair Sports. (n.d.). Wheelchair Tennis.

Wheelchair Basketball Canada. (2021). About the sport.

Wheelchair Basketball Canada. (2021). Equipment.

Wheelchair Rugby Canada. (2018). Rules and equipment.

Information for “What adapted winter sports are available?” is based on:

Canadian Ski Council. (2018). Skiing is for everyone!

XCSkiResorts. (2016). Nordic adaptive sit-skis bring freedom to mobility impaired persons.

BC Hockey Saanichton, BC. (2016). Para Hockey Brochure Guide.

Information for “What water sports are available?” is based on:

Move United. (n.d.). Sailing.

Disabled Sailing Association of British Columbia. (2021). Sip ‘n’ Puff Technology.

Creating Ability. (2021). Seating systems.

Creating Ability. (2021). Paddle adaptations.

Image credits

  1. Man on Arm Erg by SCIRE Community
  2. BC Wheelchair Rugby Day 1 293©Melissa Nemeth, CC BY-SA 2.0
  3. Noun Project
  4. Noun Project
  5. Noun Project
  6. Shark ©Sunrise Medical 2021
  7. Replacement parts for Invacare Top End Handcycles ©, LLC 1998-2021
  8. Van Ram Fun2Go Tandem © 2020
  9. Batec Hybrid ©Batec Mobility
  10. Invacare top end crossfire all terrain wheelchair ©Invacare Corporation 2021
  11. Top end preliminator youth racing wheelchair – custom version. ©How I Roll Sports, LLC 2018
  12. Harness Glove ©Harness Designs Wheelchair Gloves
  13. Wheelchair Tennis ©BC Wheelchair Sports
  14. Wigan Warthogs Wheelchair Basketball-2 ©Andrew Spillane, CC BY-ND 2.0
  15. Equipment ©International Wheelchair Rugby Federation 2013-2021
  16. London 2012 Paralympics Wheelchair Rugby (Murderball) ©Sum_of_Marc, CC BY-NC-ND 2.0
  17. Monique-1 Mono Ski ©Enabling Technologies 2021
  18. Dynamique Bi Ski ©Enabling Technologies 2021
  19. Woman using sit ski – photo by northeast passage ©U.S. Forest Service – Pacific Northwest Region, Public Domain Mark 1.0
  20. Sledge Hockey: Italy/Sweden ©Mariska Richters, CC BY-NC-SA 2.0
  21. Terry in Matin 16
  22. Outfitted Kayak ©Creating Ability 2021
  23. Stabilizing Outriggers ©Creating Ability 2021


Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Wheelchair Maintenance

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Author: Sharon Jang | Reviewer: Ian Denison | Published: 29 February 2024 | Updated: ~

Maintaining your wheelchair is important to expanding its lifespan and injury prevention. This page provides an overview on how you can keep your wheelchair in good shape.

Key Points

  • Maintaining your wheelchair on a regular basis can help save money on repairs, extend the life of your wheelchair, and prevent injuries.
  • Maintenance involves two aspects: checking to make sure your wheelchair is in good shape (inspections) and minor tune-ups.
  • Maintaining your wheelchair is beneficial, but does not replace an annual wheelchair inspection by your wheelchair provider.

Regularly maintaining your wheelchair can help you save money from repairs, extend the life of your wheelchair, and prevent injuries. Some weak evidence research has found that individuals who did not regularly maintain their wheelchairs are over 10 times more likely to have a wheelchair-related accident. Knowing what to do when your wheelchair malfunctions may provide you with more independence and reassurance when travelling. Although more complicated and technical maintenance should be left to a wheelchair maintenance expert, there are many things you can do at home yourself.

Maintenance scheduling

The numerous maintenance tasks listed in this article may seem overwhelming. This article goes over many aspects of your wheelchair to inspect and covers multiple maintenance tasks to be completed. Completing all of these tasks in one go may require a lot of time and energy. If this is not feasible for you, try breaking up the monthly maintenance items into different weeks. For example:

  • Week 1: Check tires– inspect tires/casters, check wheel lock.
  • Week 2: Frame maintenance – inspect frame, check nuts and bolts, wipe down frame.
  • Week 3: Wheel Maintenance – clean axles, lubricate if needed, inspect wheel bearing, check spokes.
  • Week 4: Supports – check back rest, foot support, clean upholstery.
Tool Image Purpose
Wrench To turn nuts and bolts or to prevent them from turning when loosening or tightening.
Lubricant (e.g., graphite, PTFE/Teflon) Lubricates moving parts and prevents them from corroding.
Screwdrivers (with various heads)
Used to undo or tighten screws on a wheelchair.
Hex keys (Allen keys) Used to turn sockets with a hexagonal head. You will either need metric or imperial hex keys, depending on your wheelchair.
Tire pumps Standing tire pumps are recommended as they are needed to pump tires up to over 50 psi.
Tire levers Used to lift the tire off and to access the inner tube of a tire.

Several parts of a manual wheelchair may require maintenance. We discuss these maintenance checks below. If you find anything wrong with your wheelchair, contact your wheelchair service provider.

Weekly maintenance

Tire inflation

To maximize pushing efficiency, it is important that your tires are always properly inflated. Weak research evidence suggests that tires deflated by more than 50% result in using more energy when pushing. However, it must also be noted that softer tires perform better on soft surfaces, such as grass or gravel. For general daily use, tires should always be inflated to the recommended values indicated on the side of the tire.

There are two ways to check tire pressure:

  1. For a more accurate reading, use a standing bicycle tire pump with a gauge.
  2. If you do not have a pump with a gauge, press down firmly on your tire with your thumb. If it presses in at all, it requires inflation.

Types of valves: Presta (left), Schraeder (right)

The amount of air required for your specific tire is indicated on the side of your tire. To inflate your tire, a standing pump, a gas station pump, or a hand pump may be used. Note that most hand pumps are not able to inflate tires over 50 psi; a high-pressure hand pump is required for tires. In addition, gas station pumps are only able to pump up Schraeder valves as Presta valves require an adaptor.

Refer to our article on Manual Wheelchairs for more information!


Your cushion is essential to maintaining a good seated posture and for skin health. To ensure that your cushion is in its best shape, inspect the cushion and cover on a weekly basis. When inspecting the cushion cover, look for any holes, signs of wear, or flaking on the underside of the cushion, and make sure the zipper is working properly.

Maintaining your cushion depends on what kind of cushion you have:

  • For gel cushions: knead the gel from outside to inside. Ensure that the gel is redistributed, and that gel is present under areas of high pressure (e.g., in the area of your sit bones). In addition, ensure that there are no leaks in your cushion.
  • For foam cushions: check that the foam is not breaking down or crumbling anywhere.
  • For air cushions: ensure that your cushion is properly inflated. Check for leaks. If you think your cushion may have a leak, submerge it underwater and check for bubbles.

Monthly maintenance

Cushion and cushion cover

Keeping your cushion clean is important, as dirt on the cushion may lead to skin breakdown, and may leave a smell on your cushion. Once a month, wipe down the cushion with a clean damp cloth and soap. Wash the cushion cover in a washing machine, and follow the instructions in the cushion guide. Make sure to hang dry the cover, as placing the cushion cover in the dryer may result in shrinkage which may result in the cover being too small for your cushion.

Intact (green) and worn out (red) tread on a wheelchair tire.15


The tires are a key component of the wheelchair subjected to daily wear. Inspect your tires once a month to make sure they are in good shape. Look for any signs of wear, cracks, bulges, looseness, damage, or flat spots.

Wheel bearing

The wheel bearings are located within the hub of the rear tire, and help to allow the wheel to turn freely and smoothly. Bearings normally wear out over time with use. You will know it is time to replace a bearing if you start hearing a knocking, or more infrequently, a squeaking sound as you wheel. If you suspect that you need your wheel bearing replaced, contact your local wheelchair service provider.

The wheel bearing should be tightened to a happy medium: a wheel bearing that is too loose may result in side to side movement of a wheel, while a wheel bearing that is too tight may result in additional resistance, resulting in an increased amount of energy spent while using your wheelchair. To check that the wheel bearings are not too tight or too loose, lift one side of the wheelchair up and spin the wheel. The tire should spin easily and should not slow and stop quickly after being spun. After the wheel stops spinning, it should spin backwards a little and should not wiggle side to side too much.

Large wheel axle

Rear wheels may be fixed (i.e., not removable) or quick release (i.e., removable). To ensure that the wheels are in place and are not loose, wiggle the wheel in all directions. If you have a fixed axle, there should be no play in the wheel. If you have a quick-release axle, some play is acceptable.

If you have a quick-release axle, test the release mechanism and ensure that the wheel securely locks back in place. A wheel that does not latch back in securely may result in an accident and should be addressed as soon as possible.

Wheel alignment – wheelchair tracking

When looking at your wheelchair from above, the two rear wheels should be parallel to each other. Having wheels that are misaligned may result in greater energy expenditure and veering of the wheelchair when pushing. Needing to constantly correct for a veer when pushing may result in reduced control over the direction that a wheelchair is moving in, a strain on one arm and/or an increased use of energy.

To check whether your tires are aligned, roll through a puddle of water and allow the wheelchair to coast. The wheelchair should maintain its direction, and the tracks of the chair should be straight.


Spokes are attached from the wheel rim (outer part of the wheel) to the hub (center part of the wheel), and help to distribute the forces of wheeling, such as the weight of the user, wheeling over surfaces, and braking. The spokes on a wheel act to prevent the tire from collapsing and adds stiffness to a wheel by acting as an anchor for the hub of the wheel.

When inspecting your spokes, you want to check that none of the spokes are bent and that there is enough tension in the spokes. Having enough tension in each of the spokes is particularly important, as having one loose spoke will lead to others becoming loose. Signs of loose spokes include a faint metallic snapping sound as you move. To check tension in the spokes, you have two options:

  1. Squeeze the spokes in pairs around the entire wheel. If a spoke gives when being squeezed gently, it may be loose.
  2. The ping test: spin the wheel and hold a pencil against each spoke. You should hear a normal pinging sound. Any spoke that sounds off indicates a loose spoke.
Wheel locks

Caster stem that is not aligned with the caster wheel.19

Casters are the small wheels found on the front of the wheelchair that help to stabilize the wheelchair. Begin by inspecting your casters for wear, cracks, looseness, tears, and bulges.

An example of a floating caster. Note the space between the bottom of the wheel and the ground.18

Secondly, to ensure that the casters are effectively stabilizing the wheelchair, check that both caster wheels are in contact with the floor and that the caster stem is aligned vertically. As the casters are required for maneuvering, it is important to ensure that they are able to turn freely around the axle. Check the casters for fluttering, or a shimmy/rapid vibration of the casters when moving.

Clean the caster wheel. Remove any dirt, lint, or hair that may have been collected in the caster axle using scissors, pliers, or tweezers. Further, clean the caster using a clean damp cloth or with a toothbrush.

Caster bearing

1. Inspect for wear. 2. An example of a handrim with scratches. 3.Inspect the tightness by pulling out on the hand rim. 4. Tighten as necessary.21

Like the rear wheel, casters consist of wheel bearings to ensure smooth rolling. To check that the bearings are at a happy medium in tension, spin the caster wheels and the caster assembly, and push the caster side to side. Grinding and excessive play in the caster bearings are indicative of a problem.


The handrims are rings connected to the rear wheel by bolts, and are used to propel the wheelchair. Most handrims are made out of plastic or metal (e.g., aluminum, steel), and may be coated in vinyl for extra grip. It is recommended to inspect your handrims monthly for wear, dents, cracks, or bends – they should be smooth all around. In addition, make sure that the hand rims are not loose. If loose, try tightening the bolts that connect the handrims to the wheel.


1. Common weld points.
2. Inspect the weld points.
3. Example of a cracked weld.22

Wheelchair frames consist of a series of metal tubes that have been welded together. Each month, check the welds to make sure that the tubes are held together. Inspect the frame for cracks or fractures. In addition, wipe down the frame each month with a clean damp rag. A toothbrush may be used to remove more difficult dirt. Avoid using a hose, power washer, or washing your wheelchair in the shower as it may cause the bearings to rust.

Nuts and Bolts

Common sites of nuts and bolts on manual wheelchairs.23

There are many nuts and bolts used on a wheelchair to hold various parts together. Loose nuts and bolts on your wheelchair may not only lead to rattling noises, but may not hold the part correctly and may fall out. Check the nuts and bolts on your wheelchair, and tighten them if loose. Make sure not to over tighten the nut or bolt, as it could damage the part or increase wheeling resistance.


As the backrest is used to support your sitting posture and can impact your skin health, it is important to check that it is in good shape. To do so, check the upholstery for tears, wear, stretching, or metal parts that have poked through. If you have a rigid back, check that the backrest does not wiggle and is tightly secured. In addition, make sure that the backrest height is level. It is possible for a backrest bracket to become loose, resulting in one side of the backrest being higher than the other.

If you have an adjustable sling back, observe the tension of the backrest as it may stretch over time. Adjust the back as needed.

Foot support

The foot support is often the first part of the wheelchair that comes into contact with obstacles. For example, it may be used to help open doors, act as bumpers, and may be scraped along the ground. As the foot support is used to help maintain posture, it is important to keep it intact. Inspect the footrest to ensure that it is not loose. If you have swivelling foot rests, ensure that they swing away with ease, and can latch back properly. Also be sure to check the footrests for wear on the pins, bolts, and bushing, and tighten these parts if necessary.

Maintaining a power wheelchair may seem intimidating given the integration of electronics, but most activities are fairly simple. Below we discuss the tasks you should complete with your wheelchair.

Refer to our article on Power Wheelchairs for more information!



Properly charging your battery is important in maintaining its health. Do not charge the battery too frequently with little use, or let your battery completely die. If you are using your wheelchair every day, charge your batteries every night. Batteries should be charged for 8-12 hours, even though the charging lamp has gone off.

Plastic shrouds

Shrouds are the plastic coverings that protect the electronics and the battery of the wheelchair from dirt and moisture. To check them, make sure that they are present and intact. Try to jiggle the shrouds around to ensure they are not loose.


The brakes are essential to safe use of your wheelchair. On a power wheelchair, the brakes are connected to the motor. When you drive, they automatically disengage, and when you stop, they automatically re-engage with an audible clicking sound. If you suspect something wrong with your brakes, try the following:

    1. Turn down the speed of your wheelchair
    2. Push the joystick forward and then stop. Upon stopping, you should hear a clicking sound. This indicates that your brakes are working.


Tire inflation, Cushion inspection

Similar to manual wheelchairs, pneumatic tires and cushions should be inspected on a weekly basis to optimize their performance. Refer to the tire inflation and cushion inspection instructions in the manual wheelchair maintenance section above.


The motor is an integral part of the wheelchair, as its job is to convert power from the battery into energy to move the chair. It is normal for the motor to make some noise when it is being used. Try to become accustomed to what your motor sounds like so you are able to detect any changes. Over time, it is normal for the motor to become a bit louder; however, excessive noise may be indicative of an issue. If you notice any sounds that you are unable to recognize, contact your wheelchair provider.

Controller and joystick

The controller of a wheelchair often consists of a power button, a screen, and a joystick. It is the interface used to control the driving, speed, and positioning of your wheelchair. Before inspecting your controller, make sure that it is switched off. There are two main aspects of inspecting the controller:

    1. Check the joystick and the rubber connection between the joystick and the control for any cracks or wear. This protective covering acts to keep dust, dirt, and moisture out of the electronics. And so damage to the covering may eventually lead to failure of the control.
    2. Check the wiring of the joystick. Ensure that none of the connecting cables are frayed or showing through the insulation.


Cushion, cushion cover, and foot plates.

Cushions, cushion covers, and footplates should be maintained and inspected at least once a month. The maintenance and checking process for these items are similar to manual wheelchairs. For more information, refer to the section “What maintenance and checks should I do for my manual wheelchair?” above.


The treads on your tire play a key role in maintaining traction and maintaining the stability and maneuverability of the wheelchair. Some tires may have less tread than others; note how much tread your tire starts off with. Check the tire treads monthly to ensure that they are not worn.


The axles of the front caster wheels of the wheelchair are the lowest to the ground, and thus are susceptible to picking up hair, dust, lint, and dirt. Buildup on your axles can lead to premature wearing and increased rolling resistance. For example, hair wrapped around the caster wheel can lead to breakage. Using a pair of scissors, tweezers, a toothbrush, or pliers, remove debris from the caster.


Inspect the frame and weld points on the wheelchair and ensure there are no cracks. Make sure all fasteners are appropriately tight.


The backrest of your wheelchair is important for support and your posture. Maintaining the backrest of a power wheelchair is similar to a manual wheelchair. Refer to the manual wheelchair section for further details.

Wiring and electronics

There are many wires throughout a powered wheelchair that are essential to making the wheelchair move. To safeguard the use of your wheelchair, make sure that all of the wires are in place and free from dirt and corrosion. If you notice any exposed wires or corrosion on the wires, take it to a dealer. If wires are hanging out or are in the way of your day-to-day use, it may be beneficial to connect the wires to a support (e.g., armrest, frame, etc) as shown below.

Diagram of the wheel locks and the bolts that can be adjusted.31

Wheel lock not locking wheels

If your wheelchair is still moving despite your wheel locks being on, first check to see if your wheels may be underinflated. Try inflating your tires to the recommended pressure. If the wheel locks are still ineffective, try adjusting the position of the wheel lock by loosening the bolts securing the clamp on the frame of the wheelchair. Slide the adjustment bar as required, and tighten up the bolts. If your brakes look like they are worn, contact your local wheelchair service provider for a replacement.

Wheelchair Keeps veering to one side

One way to check tracking is by rolling through a puddle of water. Take note of the water trail made from the wheels. Are they parallel and straight?32

As you push your wheelchair, it should travel straight forward. However, your wheelchair may sometimes veer, or pull to one side, when you intend to go forward in a straight line. Before trying to resolve this issue, ensure that your chair is actually pulling one way, and that it isn’t related to an uneven surface or unequal strength. To do this, propel your wheelchair forward as far as you can with one push. Note any deviations to a side. Turn around, and perform the same action in the opposite direction. This is to cancel out the effect of an uneven surface. If you have identified a pulling of your wheelchair in one direction, something is causing poor tracking. There are multiple reasons why your wheelchair may veer to one side when you are pushing.

  • Caster:
    • Vertical alignment of the caster may be off.
    • Caster fork may be misaligned.
    • Hair may be wrapped around one of the casters.
  • Tire:
    • Check to ensure that the tire pressure on both sides are equal.
    • Make sure that axles are mounted symmetrically on the frame.
  • Frame:
    • Make sure the frame is sitting evenly. Check that the footplates are sitting at an equal height.

Patching a flat inner tube

If you are using a wheelchair with air-filled tires, chances are you may encounter a flat tire. If you only have a patch kit on you, follow the instructions below on how to fix a tire with a patch kit. Depending on the extent of the damage done on your inner tube, a patch may suffice. Patch kits, tires, and inner tubes may be purchased from bicycle shops or wheelchair vendors.

  1. Deflate the tire as much as possible.
  2. Remove the inner tube from the tire. To do this, insert a tire lever under the edge of the tire above a spoke. Secure the hooked end of the tire lever around a spoke. Insert a second lever a few inches away from the first, and push down on it until that area of the tire flips over the rim. Slide this lever around the tire in a clockwise direction until the tire is removed.
  3. Remove the inner tube under the tire.
  4. Determine where the leak is by over-inflating the tire and listening/feeling for the air escaping. If you are unable to successfully locate the leak, submerge the air-filled tire underwater and watch for bubbles.
  5. Once you have identified the hole, mark it with a pen or marker.
  6. Use the sandpaper in the patch kit to sand the area around the hole. This will help the patch adhere to the tube better.
  7. Let the air out and apply a thin layer of rubber cement over the hole. Make sure you spread the cement over an area large enough to encompass the patch. Wait for the cement to dry.
  8. When the cement is dry, apply the patch firmly to the inner tube. Now we are ready to put the tire back together.
  9. Inflate the tube until it holds its shape.
  10. Find the valve and align it with the valve hole on the rim. Use your hands to knead the tire back onto the rim. You may need to use your tire levers to help put the last bit of the tire back onto the rim, but be careful not to pinch the inner tube.
  11. Re-inflate the tube to the recommended value on the tire wall.

To replace an inner tube instead of patching it, skip steps 4-8.

Fixing a leaky air cushion

If you notice a leak in your air cushion, it can be easily repaired with a patch. While ROHO cushions come with a patch, other brands may require you to order some from the manufacturer.

  1. Determine where the leak is. To do so, inflate your cushion and submerge it underwater. Where you see bubbles is indicative of the leak spot.
  2. Mark the hole by placing a toothpick into the hole.
  3. Allow the cushion to completely dry by laying it out on a towel.
  4. Clean the area around the hole using the alcohol wipe provided. Let it dry.
  5. Peel the backing off of the patch and place it over the hole. Firmly press on the patch until there is a good seal.
  6. Reinflate the cushion

Maintaining your wheelchair is important to its longevity and its performance. Completing various inspections and simple maintenance tasks on a regular basis is fairly simple, and can be done by yourself or a family, friend, or caregiver.

It is best to discuss all wheelchair modifications and big maintenance with your wheelchair provider should you find any major issues. This article is not intended to replace yearly professional wheelchair maintenance/tune-ups.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Evidence for “Why is wheelchair maintenance important” is based on:

Chen WY, Jang Y, Wang JD, Huang WN, Chang CC, Mao HF, Wang YH. Wheelchair-related accidents: relationship with wheelchair-using behavior in active community wheelchair users. Archives of physical medicine and rehabilitation 2011;92(6):892-898.

Evidence for “What maintenance should be done for a manual wheelchair?” is based on:

Boninger, M., Kirby, R.L., Oyster, M., Pearlman, J. Cooper, R.A.,…Toro, M. (2017). Wheelchair maintenance training program: Clinician’s reference manual. Retrieved from:

Golden, J., Colescott, D. (2017). Manual wheelchair maintenance checklist [PDF]. Retreived from:

Manual Wheelchair Maintenance Checklist.(n.d.). Retreived from:

Model systems knowledge translation center (2018). Maintenance guide for users of manual and power wheelchairs [PDF]. Retrieved from:

Sawatzky BJ, Miller WC, Denison I. Measuring energy expenditure using heart rate to assess the effects of wheelchair tire pressure. Clinical Rehabilitation 2005;19(2):182-7.

Evidence for “What maintenance should be done for a power wheelchair?” is based on:

Model systems knowledge translation center (2018). Maintenance guide for users of manual and power wheelchairs [PDF]. Retrieved from:

Boninger, M., Kirby, R.L., Oyster, M., Pearlman, J. Cooper, R.A.,…Toro, M. (2017). Wheelchair maintenance training program: Clinician’s reference manual. Retrieved from:

Evidence for “What are some simple repairs I can do?” is based on:

Denison, I. (2006). Wheelchair maintenance series [PDF]. Retrieved from:

Image credits

  1. Crescent brand 8-inch adjustable wrench. ©Rico402. CC0 1.0
  2. WD-40 Specialist Dirt & Dust resistant dry lube PTFE spray. ©WD-40 2020
  3. Screw head – slotted. ©Inductive load. Public domain.
  4. Diagram of a screw head – Phillips. ©Inductive load. Public domain
  5. Diagram of a screw head – Pozidrive. ©Inductive load. Public domain
  6. Diagram of a screw head – Robertson square drive. ©Inductive load. Public domain
  7. Diagram of a screw head – Torx. ©Inductive load. Public domain
  8. Construction tool hardware construct allen key. ©Max Pixel. CC0 1.0
  9. Lezyne and Topeak Road Morph bike pumps. © CC-BY-2.0
  10. Different kinds of handicapped equipment. © Modified by the SCIRE Community Team
  11. Tyre Levers ©Ian Harvey. CC0
  12. Checking tire pressure. ©Manual Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  13. Types of tire valves. ©Manual Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  14. Checking cushion cover. ©Manual Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  15. Tire treads. ©Manual Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  16. Checking the wheel bearing. ©Manual Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  17. Inspecting spokes. ©Manual Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  18. Floating caster. ©Manual Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  19. Misaligned caster stem. ©Manual Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  20. Cleaning caster. ©Manual Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  21. Inspecting handrim. ©Manual Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  22. Inspecting wheelchair frame. ©Manual Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  23. Nuts and bolts locations. ©Manual Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  24. Checking backrest. ©Manual Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  25. Modified from: Wheel isolated ©MBGX2, Pixabay License
  26. Inspecting shrouds. ©Power Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  27. Checking the braking mechanism. ©Power Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  28. Tire treads. ©Power Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  29. Caster wheels. ©Power Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  30. Tying up wires. ©Power Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.
  31. Wheel lock. ©Ian Denison. Used with permission
  32. Wheelchair tracking. ©Manual Wheelchair Maintenance Program. CC-BY-NC-ND-3.0.


Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Wheelchair Seating

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Author: Sharon Jang | Reviewer: Emma M. Smith | Published: 25 May 2020 | Updated: ~

Wheeled mobility devices like wheelchairs and scooters are an important part of independent living after spinal cord injury (SCI). This page provides an overview of the basics of wheelchair seating after SCI.

Key Points

  • Wheelchair seating includes parts of the wheelchair that help you maintain a proper and comfortable posture when seated. This includes the backrest, foot rests, and cushion.
  • Proper wheelchair seating is important to prevent pressure sores, maintain posture, and promote function.
  • There are many different types of seating cushion, each with its own benefits and drawbacks.
  • There are three main aspects of backrests to be considered when getting fitted to a wheelchair: the height, the shape, and the stiffness.

A wheelchair seating assessment is a complex process where healthcare professionals assess your body and fit you to a wheelchair to suit your needs. How you fit in your wheelchair can significantly impact your health and comfort while using your device. A proper seating assessment can be used to prevent conditions (for example, spine deformation) from getting worse, to correct posture, and to accommodate for other aspects that are not changeable. The seating process is done in combination with other rehabilitation interventions (such as exercises, physical therapy, and spasticity management), and should be done with specific therapeutic goals in mind.

In this document, we will focus on the components on seating. Seating components consist of backrests, cushions, and accessories (e.g., footrests and arm rests). Having appropriate seating is important to having good posture while in your wheelchair, being able to function while using the wheelchair, and maintaining good skin health.

Refer to our article on Wheelchair Provision for more information!

Pressure sores

As you may be spending the majority of your time in your wheelchair, sitting pressures are of concern to skin health. Research (moderate evidence) has suggested that the sitting postures of individuals with SCI are different than able-bodied individuals. In the SCI population, higher sitting pressures are exhibited. Up to half of pressure ulcers occur on the sit bones, and are likely to have developed when sitting. Having a proper cushion suited to the way you sit can help to prevent pressure sores by redistributing pressure.

Maintaining posture

Your wheelchair setup can have a major effect on your posture while seated.1

The way your wheelchair is set up can impact your sitting posture. After an SCI, you may not be able to control the stability of your trunk, which can lead to spinal deformities and abnormal sitting positions. However, the use of a proper cushion and supports can help address sitting posture. For example, one study (weak evidence) suggests that the use of lateral supports (i.e., pads supporting the side to prevent side to side leaning) can help improve the alignment of the spine and to help improve posture while reducing the amount of effort required by muscles for postural control.

Psychosocial concerns

The way you are able to present yourself while sitting in your wheelchair may impact your psychosocial health, or your sense of confidence and self-esteem.

Quality of life

Having proper seating may impact your quality of life. Good seating can allow you to fully participate in leisure activities, and may allow you to go to school or to work. These activities depend on your sitting tolerance (how long you are able to sit in your chair comfortably) and your ability to effectively travel in your wheelchair.

There are two main purposes of wheelchair cushions: 1) to help improve function and achieve a balanced posture, and 2) to redistribute the pressure applied by the sit bones when seated. Taken together, the cushion can impact the amount of support provided, which in turn determines how long someone can sit for, how easily transfers can be done, and posture of the hips. There are many types of cushions available on the market, as no one cushion is suitable for all individuals with SCI. To determine which is best suited for your needs, various factors are considered, including:

  • The amount of pressure reduction/redistribution required
  • Temperature effects (warm temperatures may lead to sweating, which may make the skin more vulnerable to injury and infections)
  • Your level of injury
  • Your ability to relieve pressure off your sit bones
  • Your transfer techniques
  • Your lifestyle

Although new cushions may be able to provide support and redistribute pressure applied by the sit bones, the effectiveness of a cushion decreases over time. Some research studies have looked into factors that impact deterioration of a cushion. Weak evidence suggests that how a cushion is used is a bigger indicator of deterioration compared to age of the cushion. For example, factors such as how you transfer in and out of your wheelchair, frequency of curb jumps or high vibration activities, exposure to the elements (rain, snow, etc.), moisture, and exposure to extreme temperatures can negatively impact the quality of your cushion.

When sitting, pressures are created (orange) from the force of your sit bones on your buttock.2

During offloading, a greater surface area of the buttock is in touch with the cushion.3

Pressure sores develop when there is a lot of pressure applied at one point. We can counter this focussed pressure through pressure redistribution, i.e. spreading out the sitting pressures. This can be done in three ways: offloading, immersion, and immersion and envelopment.

When offloading, pressure is distributed over a greater surface area. To achieve this, pressure is distributed over the majority of the buttock (i.e., more of the buttock is in contact with the cushion) rather than just on the sit bones (see top right image). To encourage this position, a piece of the cushion may be taken out so there is a grooved surface.

Immersion and envelopment is a combination of sinking into the cushion and having the cushion form to the shape of your buttock.5

During immersion, the buttock sinks into the cushion.4

Immersion refers to a property of the cushion material, which allows the body to “sink” into it. Given the material’s ability to be compressed, pressure is redistributed by increasing the amount of body surface area that is in contact with the cushion.

Immersion and envelopment redistributes pressure by allowing the body to sink into the material, while the material conforms to the body’s shape. This maximizes pressure distribution by increasing the amount of surface area in contact with the cushion.

There are five common types of cushion material: foam, gel, air, honeycomb urethane, and alternating pressure.

Foam cushions

Foam cushions require protection from getting wet. The cushion above features an extra lining under the cushion cover to help keep it dry.6

Foam cushions are a cheaper option, and come in a variety of densities, ranging from soft memory foam to higher density foam. Foam is able to adapt to shapes, is low maintenance, and can provide support while spreading sitting pressures. One downside to using foam is that it wears out and loses its shape quickly. In addition, foam cushions are only able to provide a limited amount of pressure relief and comfort. Foam cushions also must be protected from getting wet. The use of foam cushions is recommended for those with basic sitting needs.

Gel cushions

A variety of gel cushions exist. These include a gel matrix (left) and a gel cushion (right).7

There are different types of gel cushions including gel matrix and gel cushions. Gel cushions aim to provide seating comfort by using gel placed on top of a layer of supportive foam. Gel cushions are able to relieve pressure points and distribute pressure over a larger area, while providing a stable surface to support positioning. They may also help counter effects of high temperatures with its cooling properties. Some drawbacks to using a gel cushion include heavier weight and a lack of shock absorption. Gel cushions also have the potential to “bottom out” (when all the gel is pushed aside, massaging may be required to redistribute the gel), and a potential for leaks.

Air cushions

Air cushions are often comprised of a group of small air-filled cells. In some air cushions, the cells are interconnected, while other versions contain multiple separate air sacs contained within a cushion cover. These cells support the weight of the user, and spread out the pressure of sitting through shifting air to the surrounding cells. These cushions are customizable in regards to the number of cells and the amount of air each cell is able to hold. If the cells are interconnected, the amount of air in the cushions can be adjusted using a pump. Moderate evidence has suggested that the use of air cushions can reduce the risk of a pressure sore through reducing the amount of pressure produced while sitting and promotion of air flow. Furthermore, air cushions are generally waterproof. Although these cushions are great for providing pressure distribution, they are not optimal for stability and postural support. In addition, they may be considered high maintenance as the pressure of the cushion has to be checked frequently and manual pumping of air into the cushion is required.

Honeycomb urethane cushions

These light-weight durable cushions resemble a honeycomb in that they are composed of multiple open cells. These cells are able to distribute pressure evenly while avoiding the risk of being punctured. Air flow is also promoted throughout the open cells to prevent skin breakdown. As these cushions are made out of urethane, a material that resembles rubber, they also provide good shock absorbance. However, compared to other cushions, they provide moderate positioning capabilities and are not modifiable in shape.

Alternating pressure cushions

Alternating pressure cushions consist of multiple air bladders (similar to an air cushion) with an added battery-operated microprocessor that controls the amount of air in each part of the cushion. Every 4-6 minutes, the air in each segment of the cushion alternates (i.e., inflates or deflates) to help relieve pressure of the users’ bottom. This cushion is suitable for individuals who are unable to effectively relieve seated pressure. There has been weak evidence suggesting that alternating pressure cushions have provide good user satisfaction and comfort. Some negatives for this cushion include its high cost, heavy weight (as it requires a pump and a motor), and susceptibility to punctures.

While cushion marketing may promote a reduction in sitting pressure, more research is required to determine whether reducing the pressure on the sit bones or decreasing risk factors will prevent pressure ulcers. Pressure mapping is one technique that may be used to help determine the areas that are prone to pressure sore.

Refer to our article on Pressure Mapping for more information!

Custom Contour Cushions

These cushions are made custom to the shape of your buttock in an attempt to reduce pressure. Often, custom contour cushions are made with a combination of the aforementioned materials, accounting for the high pressure areas identified by pressure mapping. There is moderate research evidence that suggests that custom contoured cushions may create a safe sitting surface for individuals with SCI through the ability to redistribute sitting pressures. There is also weak evidence that using a custom contour cushion may help increase sitting stability and posture. If using a custom contour cushion, avoid getting the cushion wet as it may deform, and be careful to properly position yourself on the cushion as there is only one position that is optimal for comfort and pressure distribution.

The main purposes of backrests are to provide stability and support to the trunk and the hips. Backrests are adjustable in three different ways: the height, the shape, and the stiffness.


For manual wheelchair users, the height of the backrest can vary. Low backrests provide support for the lower back, and are often preferred by active users as they allow for more mobility in the upper spine. However, the use of a low backrest requires complete or partial trunk control, as it does not provide much stability. Higher backrests typically span the majority of the back, but should come up to just under the shoulder blades. A higher back rest can provide more support, but a backrest that is too high may hinder mobility.

There has been some research on the impact of various backrest heights on the range of motion required for propulsion and reaching/grasping motions. One study (weak evidence) has shown that the height of the backrest may influence the efficiency of pushing a manual wheelchair. In particular, the authors suggest that a low back rest may be more beneficial for wheelchair propulsion, as it allows for greater movement in the shoulder, a greater push rate (i.e., more pushes per minute), and a greater propulsion stroke. In addition, a lower back rest has been found to allow paraplegics to apply more force when propelling their wheelchairs. However, with regards to reaching, a (weak evidence) study found that backrest height did not have an effect.

As power wheelchair users do not need to manually propel their wheelchair, the height of the backrest is typically higher. These backrests typically span the entire length of the back, and provide more support to the spine. Moreover, having a taller backrest can provide a resting position for tilt or recline functions.


Backrests generally come in three different shapes: flat, general contour, and custom contoured.

Flat backrests

Flat backrests are flat or slightly curved in shape, and often consist of a stiff flat surface (e.g., plastic, plywood) that is layered with foam and covered with material. This style of back allows for the greatest range of motion of the arms, thus creating increased freedom. Another advantage of the flat backrest is that it is very adjustable and can accommodate a large variety of support accessories, such as lateral supports, chest straps, and headrests. A drawback to this style of back is that it provides limited support. It does not accommodate for the shape of the spine, making it less suitable for individuals with lordosis (i.e., sway back) or kyphosis (i.e., a hunched back).

General contoured backrests

General contoured backrests are off-the-shelf backs that are shaped, but are not customized to your back. These backs provide more support than a flat back, as they have a deeper contour that can provide lateral (side) support. The effectiveness of general contoured backs is based on how well the back fits your needs; they may only be effective if you can find one that suits your needs.

Custom contoured backs

Custom contoured backs provide increased support for positioning, and are made custom to the shape of your back. This cushion is often used if you require extra positioning support, and if the general control back or flat back does not meet your needs. The creation of custom contour backs can be a lengthy and costly labour-intensive process. When creating a custom contour back, a mold of your back is taken. A seating specialist then inspects the mold to ensure that it is reflective of the shape of your back and that the contour information is accurate. The backrest is then carefully made to the specifications obtained from the measuring process. As custom contour backs are designed to fit the shape of your back to provide more support, they also impose limitations on flexibility. When transferring in and out of your wheelchair, it is also important to be properly aligned in your custom contoured backrest, as improper fitting may lead to pressure sores or skin breakdown.


A rigid back on a manual wheelchair.13

Soft backs are often found on folding manual wheelchairs.14

The stiffness of wheelchair backs are either soft or rigid. Soft backs (i.e., sling backs) are able to accommodate to the shape of the spine and can be effective if they are properly adjusted. However, they provide less support compared to rigid backs and can stretch over time depending on the fabric. Tension adjustable backs consist of interwoven straps that can be tightened or loosened to accommodate for posture. One weak study found that the use of a tension adjustable back provides more support than a normal sling back. While it provides more support for the hips, it may still result in poor posture. Rigid backs generally provide more support and can help with stability. However, rigid backs are less adjustable, and do not accommodate for the shape of the spine. Although rigid backs may be more supportive, weak evidence has suggested that rigid backs are less comfortable than sling backs among individuals with tetraplegia.

Footrests (or leg rests) are an important part of a wheelchair. They function to stabilize your legs for optimal hip and back posture, help promote redistribution of sitting pressures, and may promote circulation. Footrests come in a variety of options. Footrests may be fixed (as one plate or two), swing-away (i.e., can be moved away from the front or removed), or flip up (particularly in powered wheelchairs). Elevating footrests allow for the leg to be in a raised position, which may help alleviate some leg pain.

Having a foot rest that is too high may result in more pressure on your buttock.15

The length of the footrest hanger (i.e., the distance from the back of the knee to the heel) can impact how you are seated in the wheelchair. Having a footrest that is too short will push your knees upward, so that the bottom of your thighs are no longer in contact with the top of the seat cushion. As a result, more pressure is applied to your sit bones and there is a lessened ability to shift your weight backward if you slide forward. On the other hand, a footrest that is too long may result in sliding forward in the wheelchair. Consequently, someone with a footrest that is too long may tend to slide forward often in their chair, leading to a hunched back.

Some weak evidence suggests that footrests can affect how activities of daily living are performed, but not the types of activities performed. The use of footrest may help improve the sitting balance of individuals with a lumbar SCI, but not those with a thoracic SCI.

Arm rests on wheelchairs serve multiple purposes and offer more benefits than simply acting as a place to rest the arms. In addition to acting as an arm rest, this part is also used to help maintain posture, redistribute pressure, and to enhance functioning (e.g., transfers, stability). The benefit of using armrests is dependent on an individual’s level of injury and abilities. An individual with more control of their torso and arms will be less likely to need armrests. Some active individuals tend to find that arm rests get in the way.

Maintaining posture

Using armrests can help maintain a good seated posture for an individual using a wheelchair. By supporting the arms and forearms, weight is alleviated from the shoulders. Without armrests, the weight of your arms may pull your shoulder down, resulting in a hunched position. It is also important that your armrests are set to an appropriate height. Armrests that are too low may require the individual to lean forward to use the armrest, which may lead to hunching. If the armrests are too high, the shoulders may be pushed up too high, which can lead to discomfort.

Redistributing pressure

Armrests can act as a source of support for repositioning to alleviate pressure on the sit bones. Weak evidence suggests that individuals with paraplegia rely on armrests more than tetraplegics during weight shifting (9% of their body weight vs 5%). The researchers think that this may be the case because individuals with tetraplegia have weak arm extensor muscles, making weight relieving difficult. In addition to acting as a support to push off from, armrests can also help alleviate pressure on the sit bones by supporting the weight of your arms. By removing the weight of hanging arms, the hips are unloaded and pressure forces are redistributed.

Enhancing function

Armrests can be helpful for everyday activities such as transferring, picking up objects, and stability. When transferring, the armrests act as a source of support and are used to push up and off from, or they can be a firm object to hang onto when transferring back in. In addition, armrests may act as a source of stability when completing tasks that may challenge someone’s balance, such as picking up objects off the ground, reaching for high objects, and leaning.

There are a variety of seating accessories that can be used to optimize comfort and posture. Although accessories can be used to enhance your seating, the majority of your posture should be supported through your seating set up (i.e., the backrest, cushion, foot rest), and not through accessories.

Upper extremity accessories

Arm supports to prevent the arm from falling off the side (A) and the elbow from sliding back (B).18

Seating accessories for the arms are more often found on power wheelchairs than manual wheelchairs. This group of accessories include armrest side supports and elbow blocks. Armrest side supports help prevent the forearm from falling off the side of the wheelchair, while elbow blocks prevent your elbows from sliding backwards. The use of these accessories can help keep your arm in place, especially when driving over rough terrain, and can help with repositioning.

Lower extremity support accessories

A two-point seatbelt (left) and a four-point seatbelt (right).19-20

Various accessories are available to help support and position all parts of the lower limb including: the hips and buttock, knees, lower legs, and feet. To support the hips and the buttock, positioning belts (sometimes referred to as seat belts) can be used. When used on wheelchairs, positioning belts can help prevent the hips from sliding forward and help to keep the hips properly aligned (i.e., not tilted or rotated). Different types of positioning belts are available depending on your needs: two-point belts or four-point belts. Four-point belts offer more support to the hips if required. It is also important to note that safety belts are not the same as positioning belts. Although both may contribute towards safety, positioning belts are more specialized to help maintain your hip posture.

A pommel connected to the wheelchair.21

There are also an assortment of accessories to address knees that press inward, splay outward, or are windswept. To address knees that press inward, pommels are cushions mounted either to the wheelchair or cushion, which go between the knees to keep them separated; however, pommels that are too big may interfere with transferring. To address knees that splay outward, adductor pads can be used. These pads are placed on the outer edges of the wheelchair cushion, which support the thigh and prevent the knees from falling outward.

Some accessories for the feet and lower leg include strapping and pads. Heel and toe straps can be connected to the footplate to help prevent the foot from moving forward or backward. After SCI, this can be particularly useful to help manage tone in the lower legs, and ensure the person remains stable in their wheelchair. To support the calves, pads can be attached to the footrest. Calf pads are particularly used with power wheelchairs, as they can provide support to the calves during tilting or reclining.

Trunk Support

Lateral supports on a power wheelchair, circled in red.22

Lateral supports, straps, or upper body positioning belts are used by individuals who have difficulty maintaining an upright posture that may be caused by muscle weakness or other conditions. Lateral supports are square or rectangular pads that connect to the back of the wheelchair and rest against the trunk to promote balance and stability. Moreover, the lateral pads can also act as a clear indicator that you are out of alignment (e.g., when you notice you are heavily leaning on a lateral support, try to consciously correct your posture if possible). Chest supports, including chest straps, can help prevent tipping forward due to weakness in the abdominal and back muscles. When used properly, accessories can help with trunk support, stability, balance, and posture. Correct positioning and support of the trunk may prevent further progression of some spinal conditions, such as scoliosis. If placed incorrectly, these supports may be ineffective. For example, if they are placed too low they may not provide the support needed, while if they are placed too high they may irritate your shoulder, the nerves in your arm, or limit arm movement. When changing sitting positions, ensure to also readjust your trunk supports as they may shift as well.

Wheelchair seating is a complex procedure which includes multiple assessments by healthcare professionals to ensure that your wheelchair is best suited for your needs. Given that the majority of your day may be spent in a wheelchair, it is important to consider ways to relieve sitting pressures and to maintain your postures. To do so, some parts of your wheelchair that may be customized include the cushion, back, and leg rests. It is best to discuss all treatment options with your health providers to find out which treatments are suitable for you.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

SCIRE Community. “Powered Mobility Devices”. Available from:

SCIRE Community. “Manual Wheelchairs”. Available from:

SCIRE Community. “Wheeled mobility video series”. Available from:

Parts of this page has been adapted from the SCIRE Professional “Wheeled Mobility and Seating Equipment Following Spinal Cord Injury” Module:

Titus L, Moir S, Casalino A, McIntyre A, Connolly S, Mortenson B, Guilbalt L, Miles S, Trenholm K, Benton B, Regan M. (2016). Wheeled Mobility and Seating Equipment Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0: p 1-178.
Available from: 

Evidence for “Why is proper seating important” is based on:

Bogie K, Wang X, Fei B, Sun J. New technique for real-time interface pressure analysis: Getting more out of large image data sets. Journal of rehabilitation and research development, 45, 5236.

Mao HF, Huang SL, Lu TW, Lin YS, Liu HM, Wang YH, et al. Effects of lateral trunk support on scoliotic spinal alignment in persons with spinal cord injury: a radiographic study. Archives of Physical Medicine and Rehabilitation, 87, 764-71.

Thomson, D., Tully, P., Blochlinger, S. (n.d.). Laying the foundation for proper positioning: introduction to positioning for functional ability and wheelchair seating. [Powerpoint]. Retrieved from:

Evidence for “Why are cushions important” is based on:

Sprigle, S. (2014). Measure it: proper wheelchair fit is key to ensuring function while protecting skin integrity. Advanced wound skin care, 27, 561-72.

Sprigle S, Delaune W. (2014) Factors That Influence Changes in Wheelchair Cushion Performance Over Time. Assistive Technology, 26, 61-68.

Evidence for “How can a cushion redistribute pressure” is based on:

Endsjo, A., Mullis, S, Sharpe, L. 2019. Wheelchair seating and positioning guide. Retrieved from:

Evidence for “What kinds of cushions are there” is based on:

Sprigle S, Chung KC, Brubaker CE. (1990) Reduction of sitting pressures with custom contoured cushions. Journal of rehabilitation research and development, 27, 135-40.

Stewart, D. (2019). Comfort wheelchair cushions. Retrieved from:

Stewart, D. (2019). Comfort wheelchair cushions. Retrieved from:

Wheelchair seat cushions. (2019). Retrieved from:

Waugh, K. (2014). Custom contoured seating: Ensuring Successful Outcomes. [Powerpoint slides]. Retrieved from:

Evidence for “Backrest” is based on:

Fontein, J. (2017). What’s in a back? [Abstract]. Canadian seating and mobility conference.

Hong EK, Dicianno BE, Pearlman J, Cooper R, Cooper RA. (2016). Comfort and stability of wheelchair backrests according to the TAWC (tool for assessing wheelchair discomfort). Disability and Rehabilitation: Assistive Technology, 11, 223-227.

Samuelsson K., Bjork, M., Erdugan, A.M., Hansson, A.K., Rustner, B.  (2009). The effect of shaped wheelchair cushion and lumbar supports on under-seat pressure, comfort, and pelvic rotation. Disability and rehabilitation: assistive technology, 4, 329-336.

Schmeler, M.R., Buning, M.E. (1999). Wheelchair back supports. [Powerpoint slides]. Retrieved from:

Yang YS, Koontz AM, Yeh SJ, Chang JJ. (2012). Effect of backrest height on wheelchair propulsion biomechanics for level and uphill conditions. Archives of physical medicine and rehabilitation, 93, 654-659.

Evidence for “Footrest” is based on:

Janssen-Potten YJ, Seelen HA, Drukker J, Spaans F, Drost MR. The effect of footrests on sitting balance in paraplegic subjects. Archives of Physical Medicine and Rehabilitation, 83, 642-8.

Sprigle, S. (2014). Measure it: proper wheelchair fit is key to ensuring function while protecting skin integrity. Advanced wound skin care, 27, 561-72.

Evidence for ” What accessories are used for seating?” is based on:

Stewart, D. (2019). Wheelchair seating products – accessories. Retrieved from:

Image credits
  1. Wheelchair Posture. ©Shannon Sproule
  2. Sitting pressures. ©The SCIRE Community Team
  3. Offloading pressures ©The SCIRE Community Team
  4. Immersion ©The SCIRE Community Team
  5. Immersion and Envelopment ©The SCIRE Community Team
  6. Foam cushion ©The SCIRE Community Team
  7. Gel cushions ©The SCIRE Community Team
  8. Air cushions ©The SCIRE Community Team
  9. Honeycomb Cushion ©The SCIRE Community Team
  10. Jay basic back ©Sunrise Medical 2017
  11. Jay J2 Series Back ©Sunrise Medical 2017
  12. Ride designs custom 2 cushion ©Action Seating and Mobility
  13. ZR Back Right Product Detail ©Permobil 2020
  14. Wheelchair. ©George Hodan. CC0 1.0
  15. Modified from Disabled people set ©macrovector Freepik License
  16. Polio Wheelchair Lady ©jackcast2015, CC BY 2.0
  17. This was one of five images (PHIL #9170-9174), depicting the action of two different mobility-challenged women getting into a bathtub ©Richard Duncan, Public Domain
  18. Permobil original elbow & armrest side supports ©Permobil, 2020
  19. Hip belt, push button, 1” webbing, center pull, 6” pads. ©Adaptive Engineering Lab (AEL) 2015
  20. Hip stabilizing belt, push button, rear pull, large. ©Adaptive Engineering Lab (AEL) 2015
  21. Heavy duty flipdown abductor hardware. ©Therafin corporation
  22. BodiLink® Accessories. ©Permobil 2020


Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Wheelchair Propulsion Assist Devices

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Author: Sharon Jang | Reviewer: Jaimie Borisoff | Published: 15 May 2020 | Updated: ~

Wheelchair propulsion assist devices are pieces of equipment that can facilitate the use of a manual wheelchair. This page provides an overview of the different options available. SCIRE Community is not affiliated with and does not endorse any of the specific products mentioned on this page.

Key Points

  • Propulsion assist devices are technologies that attach to your manual wheelchair to facilitate propulsion
  • There is limited research on the effectiveness of these devices, but they are clinically well-accepted with perceived benefits associated with their use
  • There are options for both powered and non-powered propulsion assist devices, depending on your needs
  • Propulsion assist devices can be either front frame-mounted, replace your rear wheels, or rear frame-mounted
  • Propulsion assist devices are rapidly developing and changing; specific products in this article may no longer be available or unavailable in your area

An example of a front-mounted propulsion assist device.1

Propulsion assist devices are pieces of equipment that can be attached to a manual wheelchair to facilitate the ease of using a wheelchair, or expand the capabilities of a manual wheelchair. These devices generally work by reducing the amount of effort required by the user to move their wheelchair. Use of these devices may help individuals go up hills, reduce the amount of force required to start moving the wheelchair, or travel over difficult terrain such as grass. Propulsion assist devices are normally added onto the front or back of the chair frame, but also sometimes replace the rear wheels. These devices can be further split up into two categories: powered and non-powered.

As technology is rapidly progressing, novel devices are being frequently released. The development of multiple devices to fill a niche market has resulted in some products becoming unavailable in certain areas, or leaving the market altogether. The quick changes and developments in this area make conducting research on propulsion assist devices difficult. Currently, there is limited research on the use of propulsion assist devices for manual wheelchair users and most of the research is focussed on the devices that replace the rear wheels.

Using a propulsion assist device can be beneficial to manual wheelchair users. The man on the left is using a powered add-on.2

Power assist devices may be purchased by individuals with or without a prescription. Some indications for propulsion assist device use are limited strength in the upper body, or for those that are at a higher risk of an injury or pain to the arms and/or shoulders. These devices may improve participation in the community by enabling increased travel distance and access to more difficult environments.

In two studies (weak evidence), users of propulsion assist devices have reported benefits including:

  • Less strain on the cardiovascular and respiratory systems; this results in reduced overall feelings of fatigue.
  • Being able to go further with less effort (improved propulsion efficiency). This may help prevent overuse injuries.
  • Increased distance you are able to travel before feeling tired.
  • Travelling up and down hills.
  • Improved ability to travel on non-paved roads (e.g., grass, gravel, dirt), which increases the variety of spaces a wheelchair user may access.

Although there is limited research on propulsion assist devices, Pushrim Activated Power-Assist Wheelchairs (PAPAW) are the most researched device. Evidence has suggested that using PAPAWs have multiple benefits. One study provided moderate evidence for the use of PAPAWs to help individuals with SCI who have shoulder pain to propel their wheelchair further distances. The participants in this study also required less energy to wheel, and perceived that wheeling was easier with the use of PAPAWs. Other (weak) evidence has also shown that using a PAPAW may reduce the frequency of arm/shoulder injuries and the amount of energy required. Additional (weak) evidence suggests that individuals with tetraplegia using PAPAWs have improved ability to manoeuvre through a variety of textured surfaces and to complete activities of daily living.

Although propulsion assist devices can facilitate the use of a manual wheelchair, there are also some risks associated with their use. While this is not an exhaustive list, risks include:

Increased risk of wheelchair damage

Most manual wheelchair frames may not have been designed to withstand the different forces applied by propulsion assist devices. This may lead to premature wear and tear, or possible breakage, on some parts of the wheelchair, such as the footplate. Sudden breakage during use may lead to injury of the wheelchair user.

Using a propulsion assist device may increase the risk of tipping when going up or down hills.3

Decreased stability

The addition of a propulsion assist device either in front or behind the wheelchair may alter the center of gravity on the wheelchair. This may result in greater instability, increasing the risks of tipping backwards when going up and down steep hills. Forward stability may be compromised as well and induce tipping (e.g. when moving down at the bottom of a curb cut).

Greater impact forces when encountering an obstacle

Propulsion assist devices, especially motorized ones, allow wheelchair users to travel at a greater speed. However, hitting obstacles such as a rock or a curb in your wheelchair at a higher speed can result in greater forces, which may lead to a decrease in stability and increase the risk of falls.

Potential lateral stability issues

Propulsion assist devices that attach to the front pose a risk of tipping sideways. Particularly when travelling at higher speeds, sudden turns can result in tipping over.

Prior to obtaining a propulsion assist device, you should always consult your health professional. That said, some factors to consider when deciding whether to invest in an add-on include the following factors:

Upper limb function

Upper limb function is required to use these devices. For example, the individual may be responsible for attaching/detaching the device to the wheelchair, and some degree of hand function is needed for operation. Some products do have adapted controls for use by individuals with limited hand function.


The device should facilitate the transportation of the user over surfaces that they frequently travel on, or wish to travel on. Some terrain considerations include indoor travel, outdoor travel, uneven surfaces, soft terrains e.g. grass, and hills.

Transfer ability

It is important to take into consideration how a device may impact transferring in and out of a wheelchair. Will it make transfers more difficult?


If a car is used for transportation, consideration of the weight of the propulsion device should be considered. Will the weight of the propulsion assist device and the wheelchair be manageable to lift into a car? Will the propulsion assist device fit into the car?


Is the device light enough for the user to remove by themselves? Will the weight make manual propulsion more difficult when not in use (e.g. if battery is drained before end of travel)?

Interaction with wheelchair

Propulsion assist devices require a certain part of a wheelchair to connect to, which may vary between types of wheelchair (e.g., rigid vs folding wheelchairs) and types of add-on. How the device mounts to a wheelchair should be considered, including the user’s capability for performing the attachment/detachment. Additional consideration may be needed if the device is going to be used between different wheelchairs.

Addressing casters

Casters help provide stability to a wheelchair, but become a limiting factor when a wheelchair user wishes to travel off a smooth even surface. There are some devices that connect to the front of the wheelchair via the foot plate and lift up the front caster wheels. This allows the wheelchair user to travel over uneven surfaces easier, such as dirt paths, sand, and gravel. An example of this kind of device is a FreeWheel.

Mechanical advantage

There are some devices that facilitate pushing by amplifying your efforts (a mechanical advantage) using gears or levers. Using a device with a mechanical advantage will allow you to go further with a given push. One example of a device that provides mechanical advantage is a lever-propelled wheelchair. There are some lever devices that can be connected to your wheel (others require replacement of the rear wheels) that allow the user to propel by pushing the lever forward. Using a lever has two purported benefits: 1) using a longer lever to propel a wheelchair requires less force, and 2) using a lever enables a more favorable movement pattern of the hands, wrists, and shoulder. Together these may reduce the risk of injury. An example of this device is the NuDrive.

Pushrim-Activated Power-Assist Wheelchairs (PAPAWs)

A PAPAW is a manual wheelchair with motorized rear wheels. The wheels are powered by a battery, which is attached to the back of the wheelchair. This type of wheelchair is controlled by normal pushing movements using the pushrims. PAPAWs assist individuals with limited strength or arm function by amplifying the force applied to the wheels. Each push on the pushrim by the user is sensed and proportionally amplified to increase the force to continue the forward movement. This also occurs for braking and turning (e.g., the wheels would detect a backwards force and apply a stronger braking force). This allows for users to go further with a given push, or to brake more efficiently with less force. When desired, the power assist function can be turned off. One limitation of using PAPAWs is the significantly increased weight of the wheelchair, which is especially noticeable when turned off. Another limitation is that the pushrims are damaged more easily, as this is where the sensors are located. Some examples of PAPAWs include the Alber E-motion and the Quickie Xtender.

Front mounted systems

These systems attach to the front of the wheelchair frame and typically lift up the front casters. Non–powered versions exist which are propelled via cranks and chains similar to handcycles. Most often powered, these devices are able to turn manual wheelchairs into a three-wheeled “scooter”. Front mounted systems are usually controlled with a throttle controller, which removes the need to manually propel the wheelchair. They are also able to reach significantly higher speeds in comparison to other power add-ons. A disadvantage to front mounted systems is that they add length to the wheelchair, which may impact the ability to move around indoors. In addition, the devices can be fairly heavy (e.g., the typical Batec system is 25 kg), and little to no customizations can be made. Examples of front mounted systems include the Rio Mobility Firefly, Triride, Klaxon, and Batec.

Rear mounted systems

Rear mounted propulsion device generally connect to the bar underneath the wheelchair seat (i.e., the camber tube). These devices can power the wheelchair so that no manual propulsion is required, although turning and braking still require constant user control. Currently, there are two models commercially available that are light, compact, and easily attached: the SmartDrive and the Smoov. The SmartDrive is controlled with a wristband worn by the user. A double tap of the wristband (or similar accelerometer-sensed motion of the hand/arm when tapping the wheel or other surface) will activate the motor and begin accelerating the wheelchair. Another tap sets the speed, while the next double tap will stop the motor. Gripping on the handrim is usually still needed to slow down and stop the chair. Users are not required to propel the wheelchair once it is in motion; they are only required to steer. Good reaction time is required to operate the device; a learning curve is involved when first using the device. The Smoov operates via a frame mounted control knob to set the desired speed. Starting and stopping the motor is accomplished through tapping the knob. Turning, slowing, and stopping are similar to the SmartDrive operation.

Other rear-mounted systems, such as the Spinergy ZX-1, convert manual wheelchairs into a power wheelchair. The user backs up into the device, which connects to the wheelchair with a push of the button. This add-on lifts up the rear wheels of the wheelchair, converting it into a power wheelchair that is controlled with a joystick.

The use of propulsion assist devices has the potential to protect your arms and shoulders from pain and overuse injuries, and allow you to travel further with less energy and more various terrain. Many different kinds of technologies are being rapidly developed and introduced to the market to facilitate manual wheelchair use. Thus, the world of powered propulsion assist devices is ever changing. Due to this factor, the devices discussed in this article may change, or may no longer be available for purchase.

Any reference to a specific product does not constitute or imply an endorsement by SCIRE Community. Professional advice should be sought before making any health care and treatment decisions.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

SCIRE Community. “Powered Mobility Devices”. Available from:

SCIRE Community. “Manual Wheelchairs”. Available from:

SCIRE Community. “Wheeled mobility video series”. Available from:

SCIRE Community. “Wheelchair Add-ons”. Available from:

Parts of this page has been adapted from SCIRE Project (Professional) “Wheeled Mobility and Seating Equipment Following Spinal Cord Injury” Chapter:

Titus L, Moir S, Casalino A, McIntyre A, Connolly S, Mortenson B, Guilbalt L, Miles S, Trenholm K, Benton B, Regan M. (2016). Wheeled Mobility and Seating Equipment Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0: p 1-178.

Available from: 

Evidence for “What are wheelchair propulsion devices” is based on:

Choukou, M.-A., Best, K. L., Potvin-Gilbert, M., Routhier, F., Lettre, J., Gamache, S., … Gagnon, D. (2019). Scoping review of propelling aids for manual wheelchairs. Assistive Technology, 0(00), 1–15. Retrieved from

Evidence for “What are the benefits of using a propulsion assist device” is based on:

Morgado Ramirez, D. Z., & Holloway, C. (2017). “But, I Don’t Want/Need a Power Wheelchair.” Proceedings of the 19th International ACM SIGACCESS Conference on Computers and Accessibility  – ASSETS ’17, 120–129. Retrieved from

Evidence for “What are the risks of using a propulsion assist device” is based on:

Medicines and healthcare products regulator agency (2004). Guidance on the Stability of Wheelchairs, (March). Retrieved from

Ogilvie, C. (2019). Finite Element Analysis of a Wheelchair when Used with a Front-Attached Mobility Add-On by (November).

Evidence for “What should I consider when contemplating propulsion assist device” is based on:

Agency for clinical innovation (2019). Prescribing manual wheelchair with propulsion assist devices. Retrieved from:

Evidence for “What are the options for powered propulsion assist device” is based on:

Choukou, M.-A., Best, K. L., Potvin-Gilbert, M., Routhier, F., Lettre, J., Gamache, S., … Gagnon, D. (2019). Scoping review of propelling aids for manual wheelchairs. Assistive Technology, 0(00), 1–15. Retrieved from

Corfman TA, Cooper RA, Boninger ML, Koontz AM, Fitzgerald SG. Range of motion and stroke frequency differences between manual wheelchair propulsion and pushrim-activated power-assisted wheelchair propulsion. J Spinal Cord Med 2003;26(2):135-40

Nash MS, Koppens D, van Haaren M, Sherman AL, Lippiatt JP, Lewis JE. Power-assisted wheels ease energy costs and perceptual responses to wheelchair propulsion in persons with shoulder pain and spinal cord injury. Arch Phys Med Rehabil 2008;89:2080-5.

Image credits
  1. Batec Handbike. © SCIRE Community Team
  2. Moving in the community. © SCIRE Community Team
  3. Men in wheelchairs at heather lake, Mt. Baker Snoqualmie National Forest. © U.S. Forest Service – Pacific Northwest Region.
  4. Hand © Sandra. CC BY 3.0
  5. Mountain © iconcheese. CC BY 3.0
  6. Transfer © romzicon. CC BY 3.0
  7. Car © Priyanka, IN. CC BY 3.0
  8. Scales © Made, AU. CC BY 3.0
  9. Wheelchair © Satawat Anukul, TH. CC BY 3.0
  10. FreeWheel Wheelchair Attachment © FreeWheel 2020
  11. Stanley handling NuDrive Air © NuDrive Air 2020
  12. Alber E-Motion M25 © Manston mobility 2018
  13. Firefly Electric Attachable Handcycle for Wheelchair © Rio Mobility 2020
  14. Smart Drive © MAX Mobility, LLC 2019
  15. Spinergy ZX-1 © Spinergy 2020


Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Wheelchair Provision

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Author: Sharon Jang | Reviewer: Emma M. Smith | Published: 25 March 2020 | Updated: ~

Wheeled mobility devices like wheelchairs and scooters are an important part of independent living after spinal cord injury (SCI). This page provides an overview of the basics of the provision process and choosing a wheeled mobility device after SCI.

Key Points

  • Wheeled mobility devices such as wheelchairs and scooters are used to enhance mobility and independence for people with paralysis, weakness, or sensory loss resulting from an SCI.
  • There are many factors that play into device selection and set-up including the goal of the user, personal factors, and environmental factors.
  • The World Health Organization has outlined an 8-step wheelchair provision process to help ensure a smooth and successful transition into a using a new wheelchair.

Wheeled mobility devices are assistive technologies that are used to enhance mobility and independence following SCI. This may include a range of different wheeled devices, including manual wheelchairs, power wheelchairs and scooters.

Wheeled mobility devices are an important part of daily life for many people after SCI. They are used primarily to assist people with reduced mobility caused by weakness, paralysis, or loss of sensation, which can make it more difficult to move around independently. These devices assist individuals to move around and access their environment and community, which is an important part of being able to participate fully in life, including tasks of everyday living, work, social life, and recreation.

The main types of wheeled mobility devices typically used by people with SCI are manual wheelchairs and power wheelchairs; though there are also other options. The type of device is selected based on your physical abilities, needs, preferences, and available funding.

Manual wheelchairs

Manual wheelchairs are propelled by the user or pushed by another person. They do not typically have a battery or other power source. Manual wheelchairs are usually used by people who have enough muscle control and strength in the arms to propel the wheelchair forward on their own.

Refer to our article on Manual Wheelchairs for more information!

Power wheelchairs

Power wheelchairs are electrically powered devices that can be controlled by the user or another person. Depending on the level of movement control, they can be controlled by the hand, head, breath, or other specialized controls. Power wheelchairs are an alternative to manual wheelchairs and may be used when someone has limited arm control or strength, concerns with fatigue, pain, or injuries limiting their ability to propel a manual wheelchair, or a preference for powered mobility.

Refer to our article on Powered Mobility Devices for more information!

Other Devices

In addition to the many different types of wheelchairs that are available, there are several other power wheeled mobility devices such as mobility scooters and even Segways, which may be used in other circumstances, such as for people who are able to walk to some extent, but not for long periods of time.

Selecting a wheeled mobility device usually involves working together with your health team to find a device that fits best with your body, physical abilities, preferences, and lifestyle. Your source of funding is also an important factor, because mobility devices are often very expensive.

Your health team

Choosing a mobility device may involve working with several different health providers, which may include: occupational therapists, physiotherapists, equipment/assistive technology specialists, physicians, and sometimes equipment vendors like Durable Medical Equipment (DME) providers (people who sell medical equipment).


A health history, physical examination, and interview will be completed to determine your functional abilities, wheelchair fit, and which device is most suitable for you. This will typically involve asking you questions about your health history, and lifestyle. In addition, your physical abilities and posture and alignment may be evaluated to determine which equipment will best suit your needs. Assessments may also involve special technologies for seating assessment, such as pressure mapping.

Refer to our article on Pressure Mapping for more information!

Factors to be considered

A wide range of factors must be considered when selecting a wheeled mobility device to ensure that it is safe and meets your needs. These factors may include:

Physical considerations

Physical considerations include your functional abilities (e.g., amount of arm/trunk control, strength, range of motion), body measurements (e.g., weight, height, and joint positioning).

Time since injury

Your potential for recovery, such as how long it has been since the injury and whether you are continuing to see improvements in function.

Medical considerations

The activities you wish to do in your wheelchair influence the selection of your wheeled mobility device. 6

Other medical conditions that may affect your movement, positioning, and wheelchair use, including pressure injuries, spasticity, shoulder injuries, and pain.

Lifestyle considerations

Lifestyle considerations include how much time you will be spending in the chair each day, what activities you will be doing in your chair, whether you will need to get the chair in or out of your car, or if you will be using the chair for sport.

Environmental considerations

Your home and work environment need to be considered in regards to what kind of mobility device is best for you. Some considerations include whether the location is carpeted, obstacles and barriers in the built environment, and the amount of space available for you to maneuver in.

Caregiver considerations

Will other people in your life who may provide assistance to you, such as paid caregivers, family members, or health providers be helping you push the mobility device? Will they help with folding it up?

Funding considerations

Your funding, such as whether you have medical coverage and insurance to reimburse the costs of equipment.

Your personal preference

It is also important to consider your preferences in device selection!

Your mobility needs may change over time

It is important to consider that your mobility needs may change over time. For example, changes that affect your functional status, the development of new medical conditions or the development of new technologies may result in a need to reassess your changing needs over time. Regular check-ins with your health team are an important part to take into consideration how your needs may change over time.

Wheelchair prescription and set-up is an important part of fitting a wheelchair appropriately. This requires consideration of several different factors. The configuration of the wheelchair will greatly affect the overall performance of the wheelchair in the community, as well as how a person functions in the wheelchair. Set-up is also important because complications may arise when inappropriate adjustments/selections are made. Choosing the right device is an important part of making sure that your day-to-day mobility is safe and meets your needs.

It impacts your safety and the prevention of health problems

The characteristics of your mobility device can impact your health in several ways. Ill-fitting or inappropriate equipment can contribute to health problems, such as:

  • Pressure injuries from rubbing, friction or areas of high pressure
  • Overuse injuries from poor positioning or too much resistance
  • Arm, shoulder, or back pain
  • Joint contractures or spasticity from poor positioning
  • Muscle imbalances or spinal deformities
  • Postural changes
  • Discomfort

Your device and how it is set-up can also affect your safety. For example, if a chair is set-up in a manner that makes it easy to tip over, it may lead to falls.

It impacts your mobility and everyday function

The characteristics of your mobility device can also affect how you function in day-to-day life. For example, small tweaks to your wheelchair set-up can make it easier or more difficult to maneuver and propel yourself. The characteristics of your device may also affect the environments and situations that you can use it in, such as whether it can be used outside, during sports, or can be put in and out of a car independently.

It affects your participation in a number of different activities and environments

There are a variety of styles of wheelchairs and scooters, each with their own benefits and drawbacks. Properties of various mobility devices, such as the turning radius, the length and width, and the stability of the device may impact the types of activities that a wheelchair user can participate in. For example, a wheelchair that has a wide turning radius may not be able to maneuver in smaller stores with narrow aisles. Additionally, some devices perform better in inclement weather than others. This may be a consideration for individuals living in areas where it is often rains or snows.

The process of selection is a complicated process that typically involves collaboration among people with spinal cord injury, their caregivers, device prescribers (Occupational Therapists or Physical Therapists), and vendors (sometimes referred to as DME Provider or Durable Medical Equipment Provider). The World Health Organization (WHO) identifies and breaks down this complicated process into 8 important steps. These include:

1. Referral and appointment

In the first step, you will be referred to a knowledgeable health provider. The referral process varies based on the services provided by each country. Some countries may have a self-referral process, while others may require a referral to a wheelchair/mobility device service.

2. Assessment

In this step, you will be accurately assessed to determine the most appropriate wheelchair and wheelchair components for you. Factors that are evaluated during an assessment include: physical functioning, posture, lifestyle/the environment it will be used in, and the tasks that are to be performed using the wheelchair.

3. Prescription

The prescription of a device that best matches the needs of the user then occurs. A vendor or therapist will work with you to choose the right wheelchair, cushion, and parts, and note down the many details and measurements of your wheelchair. In this step, you are encouraged to try various devices and seating set ups with a clinician or vendor to determine what is the most optimal set up for you.

4. Funding and Ordering

Once a detailed prescription has been created, it is then possible to determine an accurate quote for the cost of the wheelchair. A request for funding to the appropriate source with a letter of justification is provided by the prescribing therapist and physician. Determining a source of funding should be in place prior to ordering the wheelchair. Once that has been processed and approved the vendor/DME provider can order the equipment.

5. Product preparation or initial set-up

When the equipment arrives, it will be set-up and put together for the initial fitting as prescribed by the clinician. In addition, the wheelchair is inspected to ensure that it is safe and ready for use. This step is typically completed by the vendor/DME provider.

6. Fitting and adjusting

Getting your wheelchair fitted is important to make sure your chair is suited to your needs. 10

The therapist and/or the vendor will make an appointment to check on the wheelchair to ensure that it has been properly assembled. During this time, they will also make final adjustments so that it fits properly. Some things that are checked during this step include:

  • Making sure the wheelchair is the right size
  • Ensuring that the wheelchair is properly adjusted to your needs so that secondary complications are prevented
  • Confirming that any modifications made are fitting correctly.

7. User training

In this step, you will receive instructions on how to care for your wheelchair and training on wheelchair skills. This step allows you to use your device to its greatest potential, and to receive the most benefits from the device. Some key areas that should be covered in training include:

  • How to transfer in and out of your wheelchair
  • How to handle the wheelchair
  • Basic skills to use your wheelchair
  • How to prevent and watch for pressure sores
  • How to care for the wheelchair and seating components (e.g., cushion, backrest, etc.)
  • What to do if there is a problem.

8. Follow-up, maintenance and repairs

Follow-up is often required to fine tune the set up once the equipment has been used in a variety of environments. During follow-up sessions, the effectiveness of the wheelchair will be evaluated to maximize functioning, comfort, stability, and to make sure that the equipment has been properly maintained. There is no general guideline for how often a follow-up should occur; however, follow-ups and maintenance are beneficial and can contribute to the safe use of your device.

Read our article on Wheelchair Maintenance for more information.

There are many types of wheeled mobility devices that can help you get around after a spinal cord injury. Determining which device will best suit your needs is dependent on a variety of factors. These factors are often considered in partnership with a device prescriber (such as an occupational or physical therapist), who will also help ensure your device properly fits your body and needs.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Parts of this page has been adapted from SCIRE Project (Professional) “Wheeled Mobility and Seating Equipment” Chapter:

Titus L, Moir S, Casalino A, McIntyre A, Connolly S, Mortenson B, Guilbalt L, Miles S, Trenholm K, Benton B, Regan M. (2016). Wheeled Mobility and Seating Equipment Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Loh E, McIntyre A, Querée M, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0: p 1-178.

Available from:

Armstrong, W., Borg, J., Krizack, M., Lindsley, A., Mines, K., Pearlman, J., … Sheldon, S. (2008). Guidelines on the provision of manual wheelchairs in less resourced settings. World Health Organization.

Frost, S., Mines, K., Noon, J., Scheffler, E., & Jackson-Stoeckle, R. (2012). Wheelchair service training package: Reference manual for participants. World Health Organization.

Mortenson, W. Ben, & Miller, W. C. (2008). The Wheelchair Procurement Process: Perspectives of Clients and Prescribers. Canadian Journap of Occupational Therapy, 75(3), 167–175.

Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). (2011). Wheelchair service provision guide. Retreived from:

Image credits:

  1. Image by the SCIRE Community Team
  2. Wheelchair etac cross ©Etac Sverige AB, CC BY-SA 3.0
  3. Pride Jazzy Select power chair ©Stephen B Calvert Clariosophic, CC BY-SA 3.0
  4. Welland Transportation ©Zdlpwebb, CC BY-SA 4.0
  5. Rehabilitation equipment ©satynek, Pixabay License
  6. Modifed from: wheelchair ©Saeful Muslim, CC BY 3.0 US
  7. Toillet ©Hadi, CC BY 3.0 US
  8. praying ©Hadi, CC BY 3.0 US
  9. Image by the SCIRE Community Team
  10. Image by the SCIRE Community Team


Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Powered Mobility Devices

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Author: Sharon Jang | Reviewer: Emma M. Smith | Published: 4 March 2020 | Updated: ~

Powered wheelchairs and scooters are an important part of independent living after spinal cord injury (SCI). This page provides an overview of the basics of choosing a powered wheeled mobility device after SCI. For more general information on wheelchair provision and wheeled mobility devices, please see our page on the wheelchair provision process. Although this page mentions specific products, SCIRE Community is not affiliated with and does not endorse any of these products.

Key Points

  • Power wheelchairs may be used by people who need greater support and assistance for mobility.
  • Power wheelchairs are normally classified by their drive (rear-wheel drive, mid-wheel drive, front-wheel drive).
  • There are many adjustable parts on a power wheelchair to ensure your safety and comfort.
  • Other powered mobility options other than wheelchairs are available (i.e., scooters, Segways); however, they are not often used by individuals with SCI.

A typical power wheelchair includes a metal frame containing a motor and battery, a seat with a backrest, footrests, small caster wheels in the front and/or back, and two large rear wheels at the back. It is propelled and maneuvered using a joystick or other control function.1

Power wheelchairs are mobility devices powered by a battery and motor, and operated by the user or by another person, such as a caregiver. Power wheelchairs may be controlled in a number of different ways: by hand using a joystick, by head movements through head array systems, by the breath through sip-and-puff controllers, and by other specialty controls. This allows power wheelchairs to be used by individuals with high cervical SCI.

Power wheelchairs are typically used by those with limited control of the muscles at the elbow (complete injuries above C5) or other reasons which make it difficult to propel a manual wheelchair. Additional factors that may encourage the use of a power wheelchair over a manual wheelchair include:

  • Improved independence (if the individual is unable to effectively propel a manual wheelchair)
  • Avoidance of overuse injuries
  • Increased speed (if the individual has weak upper body strength)
  • Lengthening the amount of time that a person can spend in the wheelchair
  • Improves the ability to participate in important activities more easily

Types of power wheelchairs are described by the base. The base is the bottom portion of a power wheelchair that houses the motors, batteries, drive wheels, casters and electronics. The seating system sits on top of this base. The base is classified according to the drive wheel location relative to the system’s center of gravity. The three classifications of power wheelchairs are rear-wheel drive, mid-wheel drive, or front-wheel drive, each with their own benefits and drawbacks.

Rear-Wheel Drive.2

Rear-wheel drive

Rear-wheel drive wheelchairs have drive wheels located behind the user’s center of gravity, with casters in front. Benefits of rear-wheel drive wheelchairs include increased stability when travelling at higher speeds. However, rear-wheel drive wheelchairs are the most likely to tip backwards when going uphill, and have a large turning radius which may make it difficult to maneuver in indoor or tight spaces.

Mid-wheel drive

Mid-wheel drive wheelchairs have drive wheels located right below the user’s center of gravity, with caster wheels both in front and behind the drive wheels (Image 3). Benefits of a mid-wheel drive wheelchairs include:

Mid-wheel drive power wheelchair with tilt-in space capability.3

  • Having the smallest turning radius, thus making them most effective for indoor mobility
  • Being highly sensitive to change in direction
  • Being the most stable when going up hills and uneven ground
  • Given that mid-wheel drive wheelchairs have a total of 6 wheels as opposed to 4, the user may experience a bumpier ride; however, this can be offset with good quality suspensions. Additionally, mid-wheel drive wheelchairs are not the most efficient at going over uneven ground or soft terrain – users may get stuck when going over these surfaces.

Front-wheel drive

Front-wheel drive power wheelchair with recline capability.4

Front-wheel drive wheelchairs have the drive wheels located in the front of the chair, with caster wheels behind (Figure 4). Some benefits of this type of wheelchair include:

  • Being the most stable type of wheelchair when going on uneven terrain and up hills
  • Being the best at going over obstacles
  • Having the ability to turn around tight corners well
  • Allowing the user to pull up close to surfaces as the footplate is closer to the wheelchair since there are no casters in the way

Some drawbacks to front-wheel drive wheelchair include increased difficulty turning in small spaces due to a long back end, less stability when going at high speeds (may tend to fishtail, making it hard to drive in a straight line).

Drive controls

Drive controls for power wheelchairs come in a variety of forms and they are chosen depending on the physical capabilities of the user. Joysticks are used if you have enough arm movement to drive the wheelchair. There are different styles of joysticks available for use, depending on your hand function. This may include ball shaped controls, knob shaped both large and small, stick shaped, as well as U-shaped to name a few. Selecting an appropriate joystick according to your abilities will provide control and precision when driving. For people without the strength or endurance to drive with their arms they may choose to drive with their head, chin or use their mouth with a sip and puff control that is controlled by breath.

Various types of joystick controllers include U-shaped (A), stick (B), and ball (C).5-7


Novel drive systems

With the advancement of technology, more unique drive systems are becoming available to accommodate for a range of abilities. Recently, there has been emerging evidence for:

  • Tongue drive systems: This new system allows individuals to drive a power wheelchair with their tongues. For this to work, an individual will need to have their tongue pierced and have a titanium magnetic barbell fitted. Once in place, the user will wear a headset with magnetic sensors. This allows for individuals to move their tongues to certain teeth/spots in their mouth to drive their chair.
  • Eye gaze systems: This system uses an eye tracking device, which allows the user to drive a powered wheelchair with their eyes. To maneuver, the user simply looks left to go left, looks right to go right, and blinks for 1 second to start or stop the wheelchair. Weak evidence suggests that users are satisfied with the system and that it may be feasible to accurately drive a wheelchair with the eyes.
  • Facial drive systems: New programs allow individuals to drive their wheelchair with various facial movements/emotions as they choose. This includes movements including raised eyebrows, head movement to the left/right, or head movement up/down.

Ultimately, we must note that the tongue drive system is very new, and more research will need to be conducted before its use in practice.


Positioning functions

Power wheelchairs can have the added function of repositioning the SCI user. Repositioning helps shift weight to other parts of the body. This is helpful in providing comfort, supporting posture, and lessening pressure on certain parts of the body.


Tilting a power wheelchair maintains the hip and knee angles by shifting both the seat and backrest together. This reduces the chances of rubbing on the skin when moving between positions. Generally, tilting with a power positioning device to a minimum angle of 30° is needed before the beneficial effects of weight shifting can be obtained, while a 55° tilt has been recommended. Additional benefits of tilting include assisting with respiratory function, providing a more comfortable position to rest in without having to transfer to a bed, and increasing stability and balance when travelling on uneven surfaces (e.g., hills).


Reclining a power wheelchair consists of the backrest moving backwards/downwards while the seat remains stable. This increases the angle between the seat and the backrest. Some benefits of reclining include stretching out the hips, facilitating toileting and changing catheters, and facilitating transfers for caregivers. There is some weak research evidence that suggests that reclining to 120º may help reduce the pressure applied by the buttock, but reclining back this far also increases the amount of rubbing, which can lead to sores.

Repositioning and pressure sores

One recommended strategy to prevent the development of pressure sores includes weight shifting. Relieving weight off the buttock may help prevent pressure sores by allowing the tissues under pressure to regain blood flow. This is normally done using strategies such as leaning forward or lifting off the seat. If you have a higher level of injury, you may not be able to relieve pressure off your buttock independently. This is where the tilt function of a power wheelchair can come in handy – tilting backwards may help reduce the pressure applied on your bottom and allow for proper blood flow to occur. For more information on pressure relief and sores, check out our page on pressure sores.



Some wheelchairs can support standing in people with SCI. Not only does standing decrease pressure at the sit bones and coccyx, it also provides many other physiological advantages such as maintaining bone mass density, improving circulation, and enhancing functional tasks such as reaching for items on a shelf. It can also be helpful in managing spasticity and for social interaction or certain job functions.


The elevation function of a power wheelchair raises the height of the seat. This is an option that can be added to the chair to enable individuals to reach and access things independently or without shoulder strain. It can also improve social interaction enabling the wheelchair to move to a height where they do not have to look up or be blocked in a room full of people.

Arm rests

Arm rests are multifunctional pieces that are located on the sides of the wheelchair. First, arm rests act as a support for the arm and the shoulder. When in motion, the arm rest help with balance during sudden stops, going up/down hills, and with balance in general. In addition, swelling in the arms may be reduced when the arms are kept elevated. Resting arms on the arm rest may also help maintain upper body posture as the weight of the arms is supported (versus hanging and pulling the upper body downward).

Individuals with cervical level injuries may require a specialized shaped armrest to provide support. 12

Secondly, arm rests can act as a source of stability when weight shifting to relief pressure. Individuals with a SCI can use their arm rest to push themselves up when shifting, or use the arm rest to act as a stabilizer when shifting their weight. For someone who adjusts their position often, gel padded arm rests may be used to increase comfort and support.

Arm rests can be highly adjustable based on various needs.

  • Having an arm rest that is too high up may push up the shoulders and may be uncomfortable
  • The use of adjustable arm rests may be helpful if the individual wants to be able to pull up to a table
  • Some arm rests come with a side panel built in to provide thigh support
  • Some arm rests have the function to be flipped up, while other types of arm rests may be completely removed from the wheelchair
  • A removable arm rest may be used to help facilitate transfers

Additionally, arm rests for individuals with injuries C4 or above may require special adjustments. Arm troughs (or a more formed arm rest) may be used to provide additional support to the arm to prevent it from moving. In addition, elbow blocks may be used to help support an upright position when tilting. In the case that an individual experiences spams in the arm, sheepskin or gel pads may be used to protect the skin when the arm rests in the trough.

Foot rests: footplates and leg rests

A footplate is generally a single plate (left), while foot rests consist of individual pieces (right). 13,14

Depending on the drive mode, power wheelchairs may have a footplate or leg rests. A foot plate is often connected to the base of the power wheelchair, and is one piece of metal that can be flipped up and down and supports both of the feet. In contrast, leg rests are two separate supports for each foot.

Where the foot rest sits is dependent on the drive base and the physical characteristics of the person. A rear wheel drive wheelchair has footplates the furthest away from the chair as there are caster wheels located on the front. This results in added length to the wheelchair, which may make it harder to turn. The use of a single centre-mounted footplate may help reduce the length of the wheelchair. Front wheel drive wheelchairs do not have front casters that interfere with the foot rests, as the caster wheels are located in the rear. As a result, the foot rests on front wheel drive wheelchairs do not interfere.

Some power wheelchairs may have an option for powered footrests, allowing the user to adjust the angle of the footplates through a motor. To prevent the legs from dangling when using the tilt or recline function, some power wheelchairs may have a foot rest elevation function. This function helps to increase the height and angle of the foot rest to elevate the legs when reclining, and lowers back into the default position when returning to an upright position.

The batteries on a power wheelchair are designed to run for generally 3-9 hours of continuous use, and are made to last for up to 5 years. Some factors that influence how far you can drive on one charge of your battery can be categorized into fixed and varying factors. Many of these factors impact each other, and changing one aspect may influence another.

Fixed factors

Fixed factors influence how long your battery lasts, but cannot be changed. Examples include:

  • Weight and size of the battery – a larger battery will allow for a greater driving distance, but adds to the overall weight of the wheelchair
  • The drive type of the wheelchair – rear wheel drive wheelchairs tend to use more power than a front or mid wheel drive
  • Weight of the wheelchair – a lighter chair will use less battery
  • Weight distribution – more weight applied on the caster wheels will use more battery power during manoeuvering

Varying factors

Varying factors are considerations that can influence your battery life in which you can have some control over to a certain extent. These factors include:

Using a powered wheelchair on smooth even ground in moderate temperatures can help prolong the battery life.15

  • The payload of the wheelchair – this is a combination of the user’s weight in addition to any items they may be carrying (e.g., respiratory products, groceries, battery charger, etc.). Most often the maximum payload the battery can handle is much greater than the average weight the power wheelchair carries.
  • Properties of the driving surface – driving on uneven, rough, slippery, or soft (e.g., gravel, grass) will use more battery power.
  • Temperature – using your power wheelchair in extreme weather (hot or cold) can impact how long the battery lasts for. Using your wheelchair in over 30 degrees or under 0 degrees Celsius will reduce the battery’s normal capacity.
  • Driving behaviour – performing a lot of stop and go actions, going up hills, and climbing curbs consume more battery
  • Low air pressures in the tires – if you are using pneumatic tires and they are underinflated, this will use up battery faster
  • Powered options – using the tilt/reclining functions or powered leg rest functions may reduce the driving range of your wheelchair

If you are using your power wheelchair every day, you should be charging your wheelchair daily. When charging your battery, it is better to charge it for longer amounts of time than in multiple short charges (i.e., less than 2 hours). A minimum charge time of 12 hours or longer has been recommended; power wheelchair batteries will not overcharge! If you are using a new power wheelchair, note that it may take 10-20 charges prior to the batteries reaching their fullest capacity.

While the majority of people who use wheeled mobility devices after SCI will use a manual or power wheelchair, other devices are also sometimes used.


Scooters are powered devices that are typically used for getting around in the community. They come in a variety of sizes and in 3 wheeled and 4 wheeled designs. They are often used by individuals whose functional abilities do not require a full-time wheelchair, but may need support when moving around in the community. This support may help a person move greater distances, conserve energy, or get around safely if they have impaired balance, pain, or fatigue. Scooters are typically larger devices compared to wheelchairs, and are controlled by hand controls similar to a bike or motorcycle. They are usually cheaper than power wheelchairs but do not have as small a turning radius and also cannot facilitate complex seating systems. Due to their longer length, they are also more difficult to accommodate in wheelchair taxis or vans.

Additionally, there are tiller-like devices that can be added on to powered wheelchairs. This allows powered wheelchair users to operate their device similarly to a scooter. An example of this device is the JoyBar.


Segways are powered, self-balancing two-wheeled devices with arm bars that a person can stand on to move around in the community. While Segways are not intended specifically to be a rehabilitation device, some people with higher levels of functional abilities (people who are able to stand and balance effectively) may use these devices to assist with getting around in the community in a similar way to scooters. They are considered to be smaller, faster, and more manoeuvrable than power wheelchairs. Early research has suggested that Segways may be a potential mobility option for people with SCI who have limited walking abilities, although there may be some difficulties getting on or off the device.

In more recent times, several seated Segway-like devices have started entering the market. These devices (such as the Nino), allow individuals with upper trunk function to drive the wheelchair by leaning forward and to brake the wheelchair by leaning back. More research is required to determine how useful and practical it would be for individuals with spinal cord injury.

As described in this article, many factors play into the selection and set up of a powered mobility device. This article provides you with information on the various parts of a power wheelchair that can be adjusted to suit your needs. If you think that a feature needs to be adjusted or added, consult with your health care or wheelchair provider.

Any reference to a specific product does not constitute or imply an endorsement by SCIRE Community. Professional advice should be sought before making any health care and treatment decisions.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Parts of this page has been adapted from SCIRE Professional “Wheeled Mobility and Seating Equipment” Module:

Titus L, Moir S, Casalino A, McIntyre A, Connolly S, Mortenson B, Guilbalt L, Miles S, Trenholm K, Benton B, Regan M. (2016). Wheeled Mobility and Seating Equipment Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Loh E, McIntyre A, Querée M, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0: p 1-178.
Available from: 


Evidence for “What types of power wheelchairs are there?” is based on:

Queensland Spinal Cord Injuries Services. (2019). Comparison of front, mid, and rear wheel drive power chairs. Retrieved from:

Evidence for “What parts of a power wheelchair should I know about?” is based on:

Agency for Clinical Innovation. (2020). Ke2p the big picture in mind. Retrieved from:

Boninger, M. and the Model Systems Knowledge Translation Center. (2019). The power wheelchair: what the spinal cord injury consumer needs to know. Retrieved from:

Giesbrecht EM, Ethans KD, & Staley D. Measuring the effect of incremental angles of wheelchair tilt on interface pressure among individuals with SCI. Spinal Cord 2011;49:827- 31.

Kim J, Park H, Bruce J, Sutton E, Rowles D, Pucci D, et al. The tongue enables computer and wheelchair control for people with spinal cord injury. Science translational medicine 2013;5(213):213ra166.

Kim J, Park H, Bruce J, Rowles D, Holbrook J, Nardone B, et al. Qualitative assessment of tongue drive system by people with high-level spinal cord injury. Journal of rehabilitation research and development 2014;51(3):451-466

Kim J, Park H, Bruce J, Rowles D, Holbrook J, Nardone B, et al. Assessment of the tongue- drive system using a computer, a smartphone, and a powered-wheelchair by people with tetraplegia. IEEE Transactions on Neural Systems and Rehabilitation Engineering 2016;24(1):68-78.

Laumann A, Holbrook J, Minocha J, Rowles D, Nardone B, West D, et al. Safety and efficacy of medically performed tongue piercing in people with tetraplegia for use with tongue- operated assistive technology. Topics in spinal cord injury rehabilitation 2015;21(1):61-76.

Queensland Spinal Cord Injuries Service. (2019). Powerdrive Wheelchair Features. Retrieved from:

Stewart, D. (2019). Wheelchair arm rests. Retrieved from:

United Spinal Association (2019). Wheelchair armrests – what do they really do? Retrieved from:

Evidence for “What impacts battery life” is based on

Invacare. (2020). How to charge and maintain a battery on a power wheelchair. Retrieved from:

Karman. (2020). Power wheelchair batteries: understanding how the battery works. Retrieved from:

Scootaround. (2019). How long do wheelchair batteries last? (and battery life tips!). Retrieved from:

Image credits:

  1. Modified from: Wheel isolated ©MBGX2, Pixabay License
  2. Mid wheel drive Image ©Br Yonten Phuntsok, Pixabay License
  3. Wheel isolated ©MBGX2, Pixabay License
  4. Front wheel drive ©Stephen B Calvert Clariosophic, CC BY-SA 3.0
  5. U-shaped joystick handle ©Bodypoint
  6. Large ball ©Permobil
  7. Joystick ©Wheelchair and Scooter Repair
  8. Midwheel drive power wheelchair with tilt-in-space capability ©Model systems knowledge translation center (MSKTC)
  9. Front wheel drive power wheelchair with recline capability ©Model systems knowledge translation center (MSKTC)
  10. Power elevating seat ©Model systems knowledge translation center (MSKTC)
  11. 2019 F5 Corpus VS ©Permobil
  12. Molded wheelchair arm rest ©Comfort Company
  13. Intrepid mid-wheel power wheelchair ©Intrepid
  14. Conventional footrest ©David Stewart
  15. Motorized wheelchair wheelchair elderly man ©Kevin Philips, Pixabay License
  16. Welland Transportation ©Zdlpwebb, CC BY-SA 4.0
  17. JoyBar © Joybar
  18. Segway ©Ivva,CC BY-SA 2.0 
  19. Nino Segway Wheelchair ©Gyronova


Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Manual Wheelchairs

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Author: Sharon Jang | Reviewer: Emma M. Smith | Published: 3 March 2020 | Updated: ~

Manual wheelchairs are a type of wheeled mobility device that are an important part of independent living after spinal cord injury (SCI). This page provides an overview of manual wheelchairs. SCIRE Community is not affiliated with and does not endorse any of the specific products mentioned on this page.

Key Points

  • Manual wheelchairs are typically used by people with enough movement control and strength in the arms to propel the wheelchair independently
  • A manual wheelchair consists of many different parts, most of which can be altered to suit your needs
  • Manual wheelchairs can be adjusted to prevent injury and to promote comfort
  • Multiple factors play into injuries related to manual wheelchair use, including the way you push your wheelchair, your wheelchair set up, and the surfaces you are wheeling on

Manual wheelchairs are wheelchairs that are propelled by the user or pushed by another person. They do not have a battery or other power source.

For the most part, manual wheelchairs are used by people who have enough muscle control and strength in their arms to propel the wheelchair forward on their own. For people with SCI, this typically means that a person needs to at least have function of the biceps (the muscle that bends the elbow), which is intact for people with complete injuries at C5 and below. However, it can be difficult to propel a wheelchair for individuals with C5 and C6 injuries, so only some individuals with these types of injuries will be able to do so. Use of a manual wheelchair is more common in people with control of the triceps (the muscle that straightens the elbow), which is intact in people with complete injuries at C7 and below. In some cases, a manual wheelchair can be pushed by another person or propelled using the legs.

As a bridge between the more common manual and power wheelchairs, power-assist add-ons combine features of manual and power wheelchairs to provide greater assistance for those who need it. Additionally, non-powered propulsion assist add-ons may also be used to facilitate wheeling. Propulsion assist options are available for manual wheelchairs and come in several different styles. The use of powered add-ons has been reported to improve efficiency and to reduce strain on the cardiovascular system. The following article will focus on manual wheelchairs that are propelled with the arms.

Refer to our chapter on Propulsion Assist Devices for more information!

A typical manual wheelchair contains a frame, seat with a backrest, footrests or footplate, two small caster wheels in the front, and two large rear wheels at the back. The rear wheels contain hand rims which are used to propel and maneuver the wheelchair. Wheel locks on the rear wheels help prevent the wheelchair from moving when it is not in use or when getting in or out of it.

There are many different styles of manual wheelchairs, most of which allow for the ability to adjust and change aspects of the set up. This can be important in the first few years that a person uses a wheelchair as a person’s skills and priorities may change. Nonetheless, it is important to try to get as lightweight and compact a wheelchair as possible while also ensuring it is safe, durable and flexible.

There are many different components of manual wheelchairs that can be customized and changed to find the best set-up for an individual. Below, we list some of the common options and changes that may be possible when setting up a manual wheelchair. In general, changes to the set-up of the manual wheelchair are a series of tradeoffs. Although changes are usually intended to achieve a desirable improvement (such as greater ease of wheeling), sometimes they need to be balanced with reduced stability and an increased risk of tipping over. Please speak to your health providers before making any major changes to your wheelchair set-up.

Frame design

Manual wheelchairs come in two basic frame designs, folding frames or rigid frames. Folding frames have a crossbar under the seat that allows the frame to fold in half. Rigid frames may also fold but in a different way, where the backrest folds down. In many manual wheelchairs, wheels can removed if they are being put in a vehicle.

Folding manual wheelchairs

Folding wheelchairs are designed to be folded vertically and take up minimal storage space. This allows for easy portability (such as fitting the wheelchair into a car). However, these wheelchairs also have many moving parts that may break down or loosen over time, and are heavier than rigid wheelchairs. Folding wheelchair often have flip up, swing away or swing in footrests so they may be used by individuals that do not use the wheelchair full time, can stand or take some steps, or by those who foot propel.

Rigid manual wheelchairs

Rigid wheelchairs tend to be lighter and more durable than folding wheelchairs, which makes them the common choice for people with complete SCI injuries. The rear tires often have to be removed to fit into a vehicle because they cannot fold inward. Some rigid manual wheelchairs can still be ordered with adjustability, which can be important if seating components change.


Frame materials

The majority of manual wheelchair frames are made of either aluminum or stainless steel. Ultralight and sports wheelchairs are often constructed from high performance aluminum, carbon fiber, chromium-molybdenum, nickel alloy steel, or titanium. Titanium and composites can be considerably more expensive but are more lightweight.

Seat width, depth and slope

It is important that the width, depth and slope (also known as dump) of the seat from front to back are well-fitted to the overall function and characteristics of the user. A wheelchair that is too narrow in width may cause skin problems due to rubbing, while a wheelchair that is too wide may hinder propulsion, and will interfere with the accessibility and maneuverability of the chair. A wheelchair that is too short in depth may provide insufficient support to the hips and stability to the bottom, while a wheelchair that is too long in depth may cause knee pain or a slouching posture.  In addition, an increased seat slope (i.e., one that is higher in the front than the back) makes transfers more difficult as one would need to lift up at an incline, but are better for people with a higher level of injury because this slope helps them find balance and stability to wheel.

Footrest angle and frame taper

The footplate is angled away from the frame of the chair and the post of the casters.6

When considering the footrest angle between the seat and the footplate hanger, the knee flexion range of movement and hamstring length needs to be considered as well as the visual field as the client may not be able to see their feet. For example, a greater frame angle improves wheelchair access by making the chair shorter but may make the chair more unstable in the forward direction. Some wheelchairs have a frame taper, which is the narrowing of the frame towards the front and continues down to the footplates. This improves access from the front of the wheelchair, making toilet transfers easier. However, the taper may not be compatible with the cushion and may impact the ability of the wheelchair to fold.

Rear Wheels

Spoked wheels (left) versus mag wheels (right).7,8

The rear wheels are set up with hand rims on them so that self-propelling is possible. Wheel material and the amount of air in the wheels affect how effective the wheels are in minimizing vibration or shock to prevent triggering of spasticity and to increase comfort. Wheel rims are made from a variety of materials including aircraft grade aluminum, plastic, fibreglass, reinforced nylon, titanium, carbon graphite, or steel. Types of rear wheels include: spoked wheels (made of metal, normally has more than 30 spokes), mag wheels (made out of synthetic material, less than 10 spokes), carbon-graphite mag wheels, and power assist wheels. The more spokes, the better the vibration absorption. The most common wheel size for adults is 60cm (24”) and for children it is 50cm (20”).


Airless (solid) tires tend to provide bumpier ride.9

Wheelchairs may have solid tires, foam-filled tires, or air (pneumatic) tires. Solid tires do not run the risk of popping, however, they often result in a bumpier ride. On the contrary, air tires provide a softer ride, but require regular maintenance of air pressure. A lack of air in the tires (less than 50% of the recommended PSI) makes propelling a wheelchair more difficult. It is recommended that tires be re-inflated every two months to keep the pressure above 50%. Some type of tires include: standard pneumatic tires, high pressure pneumatic tires, outdoor pneumatic tires, puncture proof tires, and solid plastic tires.

Hand rims/Push rims

Hand rims are attached to the rear wheel rim on wheelchairs that are intended for self-propulsion. This part is optional, and some users may opt not to use them. Hand rims are commonly made out of aluminum, and may be anodized or vinyl coated. Some downsides to using aluminum hand rims are that they may turn your hand black, and can become very sharp if they are damaged. Other models of hand rims have a rubber like material and assist individuals without full handgrip with their push stroke. In addition, flexible hand rims have been developed to adapt to the shape of the hand in order to reduce strain resulting from the bending action of the wrist and fingers.

Front caster wheels

The small front wheels are called caster wheels, and they help maneuver and steer the position of the wheelchair. Caster diameter, material, and position are important factors to consider that affect wheelchair balance and performance. Sizes available include 75mm (3”), 125mm (5”), 150mm (6”), 180mm (7”), 200mm (8”), and 250mm (10”). Bigger caster wheels are more stable, have a bigger turning radius, and easier to wheel over thresholds but are less maneuverable and responsive. A point of caution is that when caster wheels are trailing, a person’s weight will be more forward and may be in front of the caster wheel, which can cause tipping and is a frequent cause of falls in manual wheelchairs (see image below). Caster stem angle must always lie at right angles to the floor to ensure casters track correctly, or they may “flutter” when the wheelchair is pushed or can cause the front of the wheelchair to rise and fall during turning.

Forward casters (left) versus trailing casters (right).11

When choosing the type of caster, one should consider the most common type of surface they will be propelling on (e.g. outdoors or indoors), the desired front seat height, and the front frame angle of the wheelchair. The construction materials available for caster wheels include plastic, urethane and aluminum. Pneumatic caster tires, usually 150mm (6”)” and 200mm (8”) in diameter, have more shock absorption features making them ideal for outdoor wheeling, while 75mm (3”) and 125mm (5”) urethane caster tires are more common and are good for indoor propulsion and sport specific wheelchairs. Those who experience significant spasticity and/or discomfort when propelling wheelchairs often opt for pneumatic casters to achieve a smoother ride.

Wheel locks

Wheel locks are used on the large rear wheels for safety with transfers and when no movement is wanted. They vary in styles including push to lock, pull to lock, and scissor style locks. To decrease the force required to engage/disengage the wheel locks, extended brake levers can be applied, as they minimize the forward reach required to access the wheel locks. The type and position of the lock should be influenced by the user’s reaching ability, balance, strength, and hand function as well as the impact of wheel lock position on transfers. Some clients with good physical skills may not even require wheel locks at all.


Anti-tippers are an optional set of smaller wheels connected to a metal poles that are attached to the frame of your wheelchair 381 to 508mm (1.5 to 2″) above the ground. Anti-tippers are commonly found on rear of the chair to prevent a backwards fall, however they can also be found on the front of the wheelchair to prevent forward tipping. Anti-tippers may be especially useful for new wheelchair users, those who have recently switched to a new wheelchair, or if one’s health is declining. While they are considered a safety item, they also have drawbacks. Firstly, anti-tippers may interfere with wheelchair skills requiring you to lean backwards, such as climbing a curb or doing a wheelie. Secondly, if the anti-tippers are set too low, it may impede on going over obstacles or up hills.

There are many necessary considerations for setting up a manual wheelchair properly for mobility and function. It is important to work with a knowledgeable health care professional and vendor to ensure the correct decisions are made.

These considerations may include:

Various factors can influence your ideal wheelchair set up. In this photo, some considerations include having a dog and wheeling on grass.13

  • Activities of Daily Living: It is important to think about where you need to take your chair, how close you can get to or under surfaces, reach for things, and how easily you can remove components and put them back on.
  • Mobility: You need to consider what surfaces you will wheel on (carpet, flooring, snow, rain). How the chair will move over inclines and transitions as well as in confined spaces. Is it a primary chair or just an indoor chair or a transport chair?
  • Positioning: It is important to consider your posture, comfort and interacting with people and your environment.
  • Psychosocial: You want to consider how you look and feel and how you will interact with people and your environment.
  • Transfers: You need to look at the ability to get in and out of the wheelchair safely so the height, stability, ease of moving and weight are some of the things to consider.

The three most important adjustments to have in a manual wheelchair are back angle, axle position and seat to floor height. These adjustments are important as they can have an impact on pain, wounds, or postural issues. The wheelchair set-up is essential to allow for safety and balance of the chair.

Axle Position (vertical and horizontal)

The horizontal position of the rear wheel axle can affect how much energy is required to move the wheelchair. Studies have shown that placing the rear wheel axle closer to the front of the wheelchair can make it easier to propel. However, it can also affect the stability of the wheelchair, and make the wheelchair more likely to tip backwards. This is because there is more weight behind the axle. Decisions on where to place the axle will depend on the person’s wheelchair skills. The distance between the shoulder and the axle of the rear wheel can also affect efficiency. One study showed that greater distances may result in greater energy requirements. Adding adjustable axles to manual wheelchairs can help individuals customize their wheelchairs to improve propulsion. This can lead to reduced risks of upper body injuries specifically shoulder injuries.

Backrest height and angle

The appropriate backrest height is largely a trade-off between posture, comfort and freedom of movement. A backrest is usually 406mm (16″) tall, and often does not come up any higher than your shoulder blades – any higher and it will impede your ability to push your wheelchair. Most manual wheelchairs have the ability to modify the height of the backrest (so it can be modified as function increases or decreases). A higher backrest is seen to be more comfortable, and is often used by individuals with limited trunk functioning as it provides more support. On the contrary, a shorter back rest allows for more movement of the trunk, which can be functionally useful (e.g., it will allow you to reach for objects sideways and behind you).

Using a wheelchair with backrest height that is not optimal may have negative consequences. If the backrest is too low, there will be a lack of support which may lead to postural instability. However, most often individuals are using backrests that are too high. This may result in a limited reach (and thus reduction in functional activity), pain, and a slouching posture as a result of compensating for sliding forward.

Other Adjustments

Rear wheel lateral position (space from frame) and camber

The lateral position of the rear wheel is the distance the wheel is from the wheelchair frame. This distance can affect the overall width of the wheelchair and how accessible the wheel is.

Camber relates to the rear wheels being set on an angle from their axle position, where the distance between the top of the wheels is less than at the bottom of the wheels. The angle can range from 0º up to an extreme 12º, although the average camber for day wheelchairs varies from 0º to 4º. Some wheelchair models offer adjustability in camber angles within the same chair. Stability, wheeling efficiency, and turning maneuverability can be enhanced with wheel camber, especially when moving over side slopes. In addition, the hands are better protected against trauma because the wheels touch the floor spanning a wider area than the hands have in contact with the hand rims. Too much camber can make the overall width of the wheelchair wider so assessment of the spaces and doorways needed to access is essential when deciding on camber.

Camber and Sports Wheelchairs

A large camber is often seen on sport wheelchairs, measuring up to 15º. A greater camber is of beneficial use to wheelchair sports, as it provides more lateral support to prevent tipping over to the side when turning quickly and sharply. It also helps to create turns that are smoother and sharper when in motion.


Footrest height and length

Proper support of the feet and legs is important to the comfort and safety of the wheelchair user. If the foot and thigh is not properly supported it may result in the leg or foot moving excessively and may result in instability, pain, and spasticity. In addition, it can create areas of pressure on the leg or the foot, ultimately leading to pressure injuries. Support can be adjusted through altering the height and length of the footrest.

The foot rest should be 1-2 inches off the ground to allow for optimal clearance. If it is too low, it may catch on door threshold and other objects, and may cause difficulties when trying to go up or down hills or slopes. Should the footrest unexpectedly hit an obstacle, there is a high risk of the user falling out of their wheelchair.

Refer to our article on Wheelchair Seating for more information on footrest set-ups

Using a manual wheelchair can be tough on the user’s arms and shoulders. Research has shown that 25-80% of manual wheelchair users experience injuries in their wrists, elbows, and or/shoulders. There have been multiple (weak) studies that have identified multiple factors that can be addressed in order to reduce/prevent the chances of injury:

Muscles required for propulsion

Muscles in the chest, upper back, shoulders, and arms that are used in propelling a wheelchair.17

When pushing a manual wheelchair, many muscles in the upper back, chest, shoulder, and arms are used. Pushing a manual wheelchair is not the most efficient way of getting around, as only between 2-14% of force applied by the arms goes into propelling a wheelchair, depending on the level of injury and style of propelling. The shoulder muscles are particularly strained during wheelchair propulsion as they are relatively smaller muscles that are responsible for both stabilizing the shoulder and applying force to a wheelchair to push it forward . Shoulder pain occurs in 31-73% of manual wheelchair users, and weak evidence suggests that individuals with tetraplegia experience more pain due to greater forces being applied with their arms.


Kinematics: the technique you use when propelling a wheelchair can impact your risk of shoulder pain/injury. For example, pushing a wheelchair at increasing speeds/intensities may contribute to the development of shoulder pain. Additional factors to be considered include the angle of your joints (i.e., the elbows, wrist) when pushing, and the angle at which you push your tires at.

Propulsion pattern: the pattern you push your wheelchair with (e.g., where do your hands go when you push and after you’re done pushing) may also have an influence on your risk of injury. Some weak evidence suggests that using the semi-circular and double-loop-over may reduce the risk of nerve injury and are the most optimal ways to push your wheelchair. Further evidence (weak) has indicated that arcing may be more efficient for short bouts of high intensity pushing (like when going uphill).

Body weight: Weak evidence suggests that having a higher body weight may be related to a higher risk of injury while propelling your wheelchair. This is due to the fact that moving a heavier body requires higher forces created by the shoulders. Body weight management is important in decreasing the amount of force created in your arms when pushing your wheelchair, and reduces the risk of injury.

Wheelchair set up: Having the rear wheels on a manual wheelchair placed in a forward axle position can help improve push rim biomechanics, reduce the amount of force put on your shoulders when propelling, and the frequency of propulsion (i.e., you do not have to push as much to go as far). Research has suggested the use of manual wheelchairs with adjustable axle positions so that the rear wheels can be optimally adjusted.

Wheeling on uneven surfaces: Some research suggests that wheeling across cross slopes (such as a driveway) can increase the forces on the arm and may lead to overuse injuries. In addition, more physiological effort  (i.e., heart rate, how much oxygen is being used, rating of perceived exertion) is required to go up slopes more than 2% incline, and more physiological and physical effort is required to go up slopes greater than 8%.

Manual wheelchairs are highly customizable pieces of equipment that can be tailored to your needs. In order to optimally use your wheelchair, certain adjustments to the backrest, frame, and tires can be made. Using manual wheelchairs requires upper arm function and strength. Improper set ups and techniques may lead to injuries.

It is best to discuss all treatment options with your health providers to find out which treatments are suitable for you.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Parts of this page has been adapted from SCIRE Project (Professional) “Wheeled mobility and seating equipment following spinal cord injury” Chapter:

Titus L, Moir S, Casalino A, McIntyre A, Connolly S, Mortenson B, Guilbalt L, Miles S, Trenholm K, Benton B, Regan M. (2016). Wheeled Mobility and Seating Equipment Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0: p 1-178.

Available from: 


Evidence for “What are the components of a manual wheelchair?” is based on:

Boninger, M., and the Model Systems Knowledge Translation Center. (2019). The manual wheelchair: What the spinal cord injury consumer needs to know. Retrieved from:

Spinal outreach team and The University of Queensland School of health and rehabilitation sciences. (n.d.). Manual wheelchairs: Information resource for service providers. Retrieved from:

Evidence for “What adjustments can I make to my manual wheelchair?” is based on:

Sprigle, S. (2014). Measure it: proper wheelchair fit is key to ensuring function while protecting skin integrity. Advanced Skin Wound Care, 27(12), 561-72.

Evidence for “What are health concerns related to manual wheelchair use?” is based on:

Arva, J., Fitzgerald, S. G., Cooper, R. A., & Boninger, M. L. (2001). Mechanical efficiency and user power requirement with a pushrim activated power assisted wheelchair. Medical Engineering and Physics, 23(10), 699–705.

Boninger, M. L., Souza, A. L., Cooper, R. A., Fitzgerald, S. G., Koontz, A. M., & Fay, B. T. (2002). Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion. Archives of Physical Medicine and Rehabilitation, 83(5), 718–723.

Curtis, K. A., Drysdale, G. A., Lanza, R. D., Kolber, M., Vitolo, R. S., & West, R. (1999). Shoulder pain in wheelchair users with tetraplegia and paraplegia. Archives of Physical Medicine and Rehabilitation, 80(4), 453–457.

Gil-Agudo, A., Del Ama-Espinosa, A., Pérez-Rizo, E., Pérez-Nombela, S., & Pablo Rodríguez-Rodríguez, L. (2010). Upper limb joint kinetics during manual wheelchair propulsion in patients with different levels of spinal cord injury. Journal of Biomechanics, 43(13), 2508–2515.

Kulig, K., Newsam, C. J., Mulroy, S. J., Rao, S., Gronley, J. K., Bontrager, E. L., & Perry, J. (2001). The effect of level of spinal cord injury on shoulder joint kinetics during manual wheelchair propulsion. Clinical Biomechanics, 16, 744–751.

Rankin, J. W., Richter, W. M., & Neptune, R. R. (2011). Individual muscle contributions to push and recovery subtasks during wheelchair propulsion. Journal of Biomechanics, 44(7), 1246–1252.

Richter, W. M., Rodriguez, R., Woods, K. R., & Axelson, P. W. (2007). Consequences of a Cross Slope on Wheelchair Handrim Biomechanics. Archives of Physical Medicine and Rehabilitation, 88(1), 76–80.

Image credits

  1. Kuschall wheelchair model R33 ©Tim99~commonswiki, CC BY-SA 4.0
  2. Image modified from Different kinds of handicap equipments ©brgfx, Freepik License
  3. Wheelchair ©George Hodan, CC0 1.0
  4. Wheelchair parts (main pic) ©Memasa CC BY-SA 3.0
  5. The SCIRE Community Team
  6. Modified from disabled, stroller, the disease, wheelchair, disability, wheel, transportation, medical equipment, metal, mode of transportation, CC0 1.0
  7. Wheelchair disability paraplegic injured disabled ©stevepb, Pixabay License
  8. wheelchair, old, vintage, isolated, wheel, antique, transportation, white, retro, transport, CC0 1.0
  9. The SCIRE Community Team
  10. Wheelchair disabled person with reduced mobility man ©SGENET, Pixabay License
  11. Forward versus trailing casters ©Ian Denison
  12. Modified from Black and grey wheelchair, CC0 1.0
  13. Woman, dog, pet, friend, outdoors, grass, female, person, jacket, pal, CC0 1.0
  14. Axle Position by the SCIRE Community Team
  15. Modified from Disabled people set Free Vector ©Macrovector, Freepik License
  16. Euroleague – LE Roma vs Toulouse IC-27 ©Pierre-Selim, CC BY-SA 3.0
  17. Muscles that move the humerus ©Betts et al, CC BY-SA 4.0
  18. Stylized illustration of stroke pattern classification during wheelchair propulsion ©Emily Churton and Justin WL Keogh, CC BY 2.0


Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Pressure Mapping

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Author: SCIRE Community Team | Reviewer: Shannon Sproule | Published: 18 October 2017 | Updated: ~

Pressure mapping is a clinical technique that is used to help prevent pressure sores after spinal cord injury (SCI). This page outlines how pressure mapping is used after SCI.

Key Points

  • Pressure mapping is a technique that involves the use of a pressure-sensitive mat and computer system to measure the amount of pressure between a person’s body and a supporting surface.
  • Pressure mapping is used to help identify areas of excess pressure that may contribute to pressure sores. This can be used to help make decisions about surface options (like wheelchair cushions and bedding) and find out how effective a person’s pressure relief techniques are.
  • This technique involves the use of a flexible mat containing pressure sensors that is placed on the surface being tested and then the person is positioned on the mat. The mat is connected to a computer system that creates a color-coded diagram showing areas of pressure.
  • Pressure mapping is considered to be a useful tool for making decisions about reducing pressure that is used as a decision-making and educational tool. There is a lack of research on whether pressure mapping directly helps to reduce pressure sores after SCI.
Image of a person sitting in a wheelchair

Pressure mapping can be used on supporting surfaces such as wheelchairs.1

Pressure mapping is a technique that is used to identify areas of pressure between a person’s body and a supporting surface like a cushion or chair. A thin, pressure-sensitive mat and computer system are used to develop a map showing areas of pressure where the body contacts the surface. This technique is most often used to identify areas of high pressure associated with wheelchair seating that could contribute to the development of pressure sores.

See our article on Pressure Sores to learn more!

Pressure mapping is also used on other such as mattresses, toilet seats, car seats, sports equipment, or any other surface a person sits or lies on for periods of time that may influence their skin health.

People with spinal cord injuries have an increased risk of developing skin lesions called pressure sores. Pressure sores occur for many reasons, including increased pressure on vulnerable areas of the skin. Bony areas that come into contact with support surfaces, like the sit bones and tailbone in sitting, are highly vulnerable to increased pressure.

Learn how proper wheelchair seating can reduce the risk of pressure sores.

Circular wound on the side of the ankle bones. Wound is slightly red with bits of yellow and weeping fluid. The wound is surrounded by light pink skin.

Pressure sore on the side of the ankle.2

Pressure mapping is used to determine areas of increased pressure in certain postures on specific surfaces. It may be used to assess areas of pressure on various surfaces, such as chairs, beds, sofas, car seats, and toilet seats. This information can be used to develop strategies to reduce pressure and improve comfort in these situations.

Pressure mapping may be used as a tool to aid decision-making when selecting support surfaces and equipment, such as assessing which wheelchair cushions provide the best pressure relief for you. Pressure mapping is also used to assess the effectiveness of pressure relief techniques like weight-shifting by providing real-time feedback about the pressure during the performance of these techniques.

Pressure map placed on a wheelchair (left), flexible pressure map (center), and diagram of pressure of a person’s buttocks in sitting (right). Areas of pressure are indicated from high pressures in red (around the sit bones) to lower pressures in blue.1

Pressure map placed on a wheelchair (left), flexible pressure map (center), and diagram of pressure of a person’s buttocks in sitting (right). Areas of pressure are indicated from high pressures in red (around the sit bones) to lower pressures in blue.3

A flexible mat containing pressure sensors is placed on the surface to be tested. The person being assessed then sits on the mat. Information about pressure between their body and the seat is picked up by sensors in the mat and sent to a computer, where it is translated into a color coded diagram.

The diagram displays the pressure recorded at each sensor in the mat by number and displays areas of high and low pressure with different colors. A clinician then determines the corresponding areas on the body through a hands-on physical examination. This technique is used together with other assessments of pressure sore risk to make recommendations for reducing areas of high pressure. There may be variation in the procedures used for pressure mapping in different settings.

Cartoon of a person sitting in a chair with a clock above

Pressure mapping can be influenced by many aspects of how the procedure is done. For example, how the person positions themselves at the time of the reading and how long the person sits on the mat before the readings are taken can change the findings. There are also different types of systems that collect information about pressure differently. These factors and other concerns have led to disagreement among experts about how to best understand and interpret the results of pressure mapping for clinical use.

In addition, pressure is just one factor that contributes to pressure sores. Friction, moisture, age, body composition, time spent sitting, and many other factors also contribute to pressure sores. These factors cannot be detected by pressure mapping, which limits the use of pressure mapping as a stand-alone tool.

Pressure mapping also requires special equipment and trained health providers which may not be available in settings outside of major rehabilitation centers.

Pressure mapping is considered by experts to be a useful tool for understanding pressure and making decisions about pressure relief. At this time, most of the research that has been done on whether pressure mapping is effective for preventing pressure sores has been done in populations outside of SCI. We do not know if pressure mapping is effective for preventing of pressure sores in people with SCI.

Pressure mapping is clinical tool that may be used in rehabilitation centers to help assess the risk of pressure sores. It is considered to be a valuable tool for making decisions about reducing pressure as well as a useful educational tool for understanding pressure in different positions. There is a lack of research on whether pressure mapping directly helps to reduce pressure sores after SCI.

Parts of this page have been adapted from the SCIRE Project (Professional) “Pressure Ulcers” Chapter:

Hsieh J, McIntyre A, Wolfe D, Lala D, Titus L, Campbell K, Teasell R. (2014). Pressure Ulcers Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. 1-90.

Available from:

Barnett RI, Shelton FE. Measurement of support surface efficacy: pressure. Adv Wound Care 1997; 10(7):21-9.

Brienza DM, Karg PE, Geyer MJ, Kelsey S, Trefler E. The relationship between pressure ulcer incidence and buttock-seat cushion interface pressure in at-risk elderly wheelchair users. Arch Phys Med Rehabil 2001; 82(4):529-33.

Eitzen I. Pressure mapping in seating: a frequency analysis approach. Arch Phys Med Rehabil 2004; 85(7):1136-40.

Ferguson-Pell M, Cardi MD. Prototype development and comparative evaluation of wheelchair pressure mapping system. Assist Technol 1993; 5(2):78-91.

Hamanami K, Tokuhiro A, Inoue H. Finding the optimal setting of inflated air pressure for a multi-cell air cushion for wheelchair patients with spinal cord injury. Acta Med Okayama 2004; 58(1):37-44.

Hanson D, Langemo D, Anderson J, Hunter S, Thompson P. Pressure mapping: seeing the invisible. Adv Skin Wound Care 2006; 19(8):432-4.

Henderson JL, Price SH, Brandstater ME, Mandac BR. Efficacy of three measures to relieve pressure in seated persons with spinal cord injury. Arch Phys Med 1994;75:535-9.

Jan YK, Brienza DM. Technology for Pressure Ulcer Prevention. Top Spinal Cord Inj Rehabil; 2006; 11(3):30-41.

Kernozek TW, Lewin JE. Seat interface pressures of individuals with paraplegia: influence of dynamic wheelchair locomotion compared with static seated measurements. Arch Phys Med Rehabil 1998; 79(3):313-6.

Rondorf-Klym LM, Langemo D. Relationship between body weight, body position, support surface, and tissue interface pressure at the sacrum. Decubitus 1993; 6(1):22-30.

Shelton F, Barnett R, Meyer E. Full-body interface pressure testing as a method for performance evaluation of clinical support surfaces. Appl Ergon 1998; 29(6):491-7.

Stinson MD, Porter-Armstrong A. Seating and pressure support needs of people with cancer in the cervix or rectum: a case series on the clinical usefulness of pressure mapping assessment. Euro J Cancer Care 2007; 17:298-305.

Stinson MD, Porter-Armstrong A, Eakin P. Seat-interface pressure: a pilot study of the relationship to gender, body mass index, and seating position. Arch Phys Med Rehabil 2003; 84(3):405-9.

Sonenblum SE, Sprigle SH. The impact of tilting on blood flow and localized tissue loading. J Tissue Variability 2011;20:3-13.

Taule T, Bergfjord EE, Lunde T, Stokke BH, Storlind H, Sorheim MV et al. Factors influencing optimal seating pressure after spinal cord injury. Spinal Cord 2013;51:273-7.

Image credits

  1. Veterans wheelchair games 2009 ©U.S. Air Force photo/Staff Sgt. Desiree N. Palacios, CC0 1.0
  2. Reprinted with permission of the copyright holder, Gordian Medical, Inc. dba American Medical Technologies (courtesy of National Pressure Ulcer Advisory Panel).
  3. Image ©Cho KH, Beom J, Yuk JH, Ahn SC, CC BY-NC 4.0
  4. Sit ©Rudez Studio, CC BY 3.0 US


Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.