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Overview and Description


An estimated 5.5 million people, or 2.3% of the United States adult population, uses a wheelchair for mobility. Adults greater than age 65 are four times more likely to use a wheelchair.1,2 Independent mobility allows people to participate in work, education, and activities of daily living as well as access health care and actively contribute to the world around them. Disabled individuals without independent mobility are more likely to develop secondary health complications from delayed healthcare and be financially dependent. An effective wheelchair prescription tailored to an individual’s needs requires a multidisciplinary wheelchair assessment team, which typically includes the patient, rehabilitation engineer, occupational therapist, physical therapist, rehabilitation technology supplier, and rehabilitation physician.3

Types of wheelchairs:4,5,6

Manual Wheelchairs:

Manual wheelchairs are propelled either by the user or an attendant. If used by the individual, he or she must have good upper body function and stamina.  Manual wheelchairs are lighter in weight, easier to transport without special equipment, and require less maintenance than power wheelchairs or scooters.  Classes of wheelchairs range from standard to extra-heavy duty (for bariatric patients).

  1. Standard (35+ lbs): limited capacity for adjustment or additional options. They are most appropriate for short-term use.7
  2. Semi-adjustable lightweight (30-35 lbs): offer slightly more adjustability, but lacks rear axle adjustability. Not suitable for everyday active users.
  3. Adjustable ultra-lightweight (less than 30 lbs): Made of aluminum, titanium, or composite materials and are more durable than other manual wheelchair categories. Offers partial to full frame adjustability. Require less force to propel, therefore reducing risk of repetitive strain shoulder injuries.  These are most popular, and have high strength to weight ratios.
  4. Hemi-height: lower seat-to-floor height to allow feet to assist with propulsion. Often with swing away footrests and may have one-arm drive option.
  5. Heavy duty and extra-heavy duty: Support patients weighing >300 lb

Power Wheelchairs:

Power wheelchairs or scooters are indicated for those who cannot manually propel a wheelchair and who have the cognitive ability and coordination needed to safely propel a power device.  They may be appropriate for patients with upper limb weakness, cardiopulmonary disease, poor trunk stability, upper limb pain, limited endurance, or obesity.

  1. Power-assist manual wheelchairs: Feature motors mounted into wheel hub or as an add-on unit to wheel or axle. Augments self-propulsion in manual wheelchair so decreased upper limb strength is required.  Requires a battery system, which increases weight and can make transportation more difficult. Examples include: Xtender, E-motion, SmartDrive, Twion.  These are ideal for those who are apprehensive about committing to a power wheelchair.
  2. Power scooters: Typically have three or four wheels, Captain style seating and a tiller for steering. Requires ability to independently transfer to device, good trunk control, and good upper limb function to drive and steer.  Generally lighter in weight, less costly, and easier to transport than power wheelchairs.  Larger turning radius makes indoor use challenging. Three-wheel scooters are more maneuverable, but less stable than four-wheel scooters. Works well for those who have difficulty ambulating long distances, primarily outside the home. Examples include: Spitfire Scout, Pride Travel, Pride Maxima
  3. Power wheelchairs: indicated for individuals with tetraplegia, poor upper limb coordination, or severe range of motion restrictions. Patients may also require a power wheelchair when manual or power-assist wheelchairs do not meet their needs.  These are typically heavier and do not disassemble so transportation of these chairs is more challenging.  They can be controlled via joystick, touch-pad, head control, or sip and puff, depending on the patient’s level of impairment.  They can also have proportional control (pressure matches speed) or non-proportional control (speed not controllable). Examples include: Electra, Air Hawk, Hoveround.
    • Different categories of power wheelchairs include:
      • Group 1 – Basic configuration and seating. No special seating or controls.  No power seating options.
      • Group 2 – Folding and transport.
      • Group 3 – Combination indoor-outdoor power wheelchairs.
      • Group 4 – All-terrain power wheelchairs.
      • Group 5 – Designed for pediatric use, usually has single power option. 
    • There are groups of sports and recreation wheelchairs for fitness and recreation endeavors as well.

How wheelchair prescription applies for different levels of acuity:

Wheelchairs used in the acute setting are designed for short-term use and do not offer postural support or pressure relief. Temporarily disabled individuals can benefit from a rental chair. Individuals with chronic ambulatory deficits benefit from using a wheelchair tailored to their body types and functional needs.

Personalized fit options:2,4,8

  • Frame type and composition: rigid vs folding
  • Adjustable rear axle: horizontally and vertically. Axles placed more posteriorly are more stable, but less maneuverable. Axles placed more anteriorly are more “tippy,” but have better positioning for wheel propulsion, performing “wheelies,” and tighter turns.
  • Rear wheel camber: Angles at which the rear wheel is tilted toward the wheelchair, allowing for stability, but at the cost of being wider, which may not fit through doorway
  • Caster tires: Smaller tires in front. The smaller they are, the more likely to get stuck in cracks
  • Seat: width, depth, and dump adjustment (angle at which the seat goes back)
  • Seat cushion: foam, gel, saddle, wedge, sling
  • Armrests: length, height, and fixed vs removable; flat vs. tubular
  • Footrests: fixed, elevating, swing-away
  • Front-rigging for stability of feet
  • Adductor and abductor pads for positioning
  • Wheels: mag, spoke, composite material
  • Tires: Pneumatic vs polyurethane, various treads
  • Hand rim: chrome, aluminum, composite, foam covered; different shapes, diameters, and spacings
  • Back support: sling, solid, custom; range of heights
  • Anti-tippers (help with stability, but more difficult to pop a wheelie, patients tend to remove as they get more experienced)
  • Wheel locks (can be push or pull to lock)
  • Headrests (varies on amount of head control)
  • Optional postural supports
  • Pelvic belts (for stability and security)
  • Power Wheelchair: Front-wheel (stable for uneven terrain, hills, and small obstacles), mid-wheel (turns in place, increases indoor maneuverability, obstacles), and rear-wheel drive (handles predictably and can go at a high speed)
  • Power input devices: joystick, breath control, head array, switches
  • Seating functions:
    • Recline: positioning for ADLs, bladder management/catheterization, orthostasis, rest; can cause shear forces
    • Tilt-in-space: pressure relief, positioning, orthostasis, rest; eliminates shear forces (though never full/absolute relief)
    • Seat elevators: assist with transfers, access to higher surfaces, overhead tasks; adds height to chair
    • Standing: pressure relief, weight bearing, access to higher surfaces; won’t work with contractures, reduced bone density
    • Elevating leg rests: orthopedic issues, edema, tone; adds length; however, may make transfers more difficult

Relevance to Clinical Practice

Goals for seating and mobility:

  • Provide postural support
  • Maximize function and mobility
  • Improve safety while performing ADLs
  • Ensure skin integrity and skeletal alignment with appropriate pressure relief
  • Meet consumer’s lifestyle and environmental factors
  • Meet consumer’s aesthetics needs

Pre-wheelchair evaluation:

While wheelchair use does not change the natural history of any disorder, an appropriate wheelchair can increase functional independence, minimize disability, and contribute to quality of life and social integration. A well-fitted wheelchair can also minimize or prevent complications that might occur if the wheelchair prescription was inappropriate, such as progression of postural deformities or pressure ulcers. Co-morbid or associated conditions that may interfere with the use of a wheelchair (or require modifications to the wheelchair prescription) include cognitive deficits, spasticity or other movement disorders, vision and hearing deficits, spatial neglect, and obesity or malnutrition. Typically, patients undergo a comprehensive pelvis and hip posture exam prior to wheelchair prescription in order to assess sitting posture and subsequent wheelchair needs. While there are few absolute contraindications to wheelchair use, the patient’s ability to safely utilize a wheelchair must also be evaluated. This is especially important when prescribing power mobility.

Contraindications to manual wheelchairs include:9

  • Inability to utilize the arms for propulsion due to decreased ROM, strength or coordination (assuming this is a goal, rather than having the caregiver propel the patient)
  • Need for features that can be utilized independently by the patient, such as power tilt, recline, and seat elevation
  • Cardiopulmonary impairments may limit propulsion of a manual wheelchair, as upper extremity propulsion can increase diastolic blood pressure response and cardiac afterload, as well as require elevation in cardiac output

Contraindications to power mobility include:9

  • Visual deficits or poor motor coordination
  • Uncontrolled seizures within the last 6 months
  • Impaired cognition and judgment

Wheelchair evaluation:

Historical features to consider when determining whether wheelchair mobility is appropriate include ability to ambulate, history of falls, and activities that the proposed wheelchair will help the user to perform. Current living environment should also be assessed, as wheelchair use may necessitate modification of the environment to allow for better mobility and access. Once it has been determined that wheelchair or power mobility is indicated, the rehabilitation team can assess the patient to formulate an appropriate wheelchair prescription.3,4

Factors to consider when writing a wheelchair prescription:

  • Diagnosis and prognosis
  • Static or progressive condition
  • Age
  • Cognitive function
  • Physical ability
  • Transfer ability
  • Mental preparedness for a wheelchair
  • Body weight and habitus
  • Leisure interest
  • Environment in which the wheelchair will be used
  • Time spent in wheelchair daily
  • Level of independence in activities of daily living
  • Transportation outside the home
  • Insurance coverage
  • Medical issues such as incontinence, skin breakdown, and spasticity
  • Catheter requirements
  • Paralysis and paresis
  • Sensory issues

Physical examination should document:

  • Weight (both overweight and underweight)
  • Basic vision and visual field testing
  • Heart and lung exam in those with cardiopulmonary disease
  • Circulatory function
  • Joint swelling and deformity, such as kyphosis, scoliosis, limb contractures
  • Strength
  • Upper and lower limb range of motion
  • Coordination
  • Tone
  • Skin condition, particularly at common pressure-sensitive regions and bony prominences (e.g., elbows, wrists, buttocks, greater trochanters, calves, and heels)
  • Sensory loss, placing patient at risk for pressure ulcers
  • Spasticity and movement disorders

All wheelchair seating assessments require accurate measurements of the patient’s dimensions in a sitting position7:

  • As a guideline, generally, patients will have 90 degree angles at the knees, hips, and elbows, but this may not be feasible for everyone
  • Seat width: width at widest point of hips, buttocks or thighs (add approximately 1-2 inches total)
  • Seat depth: length from posterior buttocks to popliteal fossa (subtract 2 inches to avoid compression of the popliteal fossa)
  • Seat and footrest height: popliteal fossa to bottom of feet (add 2-4 inches to account for height of footrest off the ground)
  • Footrest length: should be 1-2 inches above floor
  • Height of back: bottom of buttocks to shoulders or bottom of scapula, depending on expectations for self-propulsion
  • Armrest height: elbow-to-buttocks distance
  • Armrest length: should consider if armrests will come up to a table or desk or take up the full length

Posture should also be assessed:

  • Sitting posture and balance
  • Spinal alignment (scoliosis, kyphosis)
  • Pelvic tilt/rotation/obliquity
  • Shoulder symmetry and posture
  • Head position
  • X-rays may help delineate bony abnormalities such as heterotopic ossification, and help differentiate fixed from flexible deformities of the spine, pelvis, and extremities

Functional assessment should include:

  • Ability to transfer
  • Ability to self-propel
  • Ability to independently complete ADLs and IADLs from the wheelchair position versus what the caregiver will have to provide
  • ability to operate the controls of a power mobility device

Other factors in the wheelchair prescription process:

Complications of wheelchair use:

Undesirable effects and injuries associated with wheelchair use are often related to improper fit or components that do not match the needs of the user. Examples include:

  • Inadequate cushioning leading to pressure ulcers
  • Improperly shaped seat base leading to trunk instability and poor posture
  • Unstable wheelchairs tipping, leading to injury
  • Improper positioning of push rims leading to upper extremity injuries
  • Inadequate trunk support leading to pain, pressure ulcers, or further deformity. Pressure ulcers are particularly common in pressure-sensitive areas including the elbow and wrist, greater trochanter, ischial tuberosity and buttock, popliteal fossa, and heel.

Overuse injuries of the upper extremities are common. Many manual wheelchair users have incomplete acquisition of wheelchair skills, which is associated with lower satisfaction and community participation, increased rates of shoulder pathology and shoulder pain and higher risk of injury.10 Some complications include impingement syndromes, rotator cuff tendinopathy and bicipital tendinitis. Wheelchair skills training programs have been shown to be effective in minimizing these overuse injuries.  There are also propulsion analyses as well.  One training program includes: www.wheelchairskillsprogram.ca

Wheelchairs frequently need repairs. Repairs and adverse consequences are more common in power wheelchairs compared to manual wheelchairs.  The wheels/casters on manual wheelchairs and electrical/power/control systems on power wheelchairs require the most frequent repairs.11

Meeting patient needs:

The success of a wheelchair prescription is the full adoption of the prescribed wheelchair in a way that meets the goals for its prescription, with few or no detrimental outcomes. Because few formal outcome tools exist, discussion with the patient and family often provides the most useful assessment for the prescribing clinicians regarding success of the wheelchair. Other factors that may influence clinical decision-making include choosing a wheelchair that will integrate into the patient’s social roles. Often the wheelchair user considers the wheelchair an extension of their own person, and thus chooses elements of the wheelchair to fit with the image they want to project. Wheelchairs can be customized in a variety of ways, including varying color choices and finish patterns, custom spoke guards, and badges sewn into the upholstery.


While it is optimal to provide patients with means of transporting their wheelchairs that is ideal for the user/chair, sometimes cost constraints limit these options and may dictate a different choice of equipment. For example, if the patient does not own a car that can transport a larger power scooter, a better option may be a lighter weight scooter that can be taken apart and transported in the trunk of the car. The trade-off may be a more frequent provision of a replacement scooter due to decreased life expectancy of the lighter weight components.

Each mobility device has transportation limitations and constraints that should be taken into consideration when selecting one for a patient. Manual wheelchairs are easily folded or disassembled and can be transported by car, but a trunk lift or hitch attachment can also be used. A modified vehicle with ramp and tie-down system may also be considered. Scooters may be disassembled and transported by car, although they are heavier than a manual wheelchair. Rear mounts can also be used. Transportation of a power wheelchair usually requires a modified van with lift or ramp and a tie-down system.

In regards to airlines, depending on size, manual wheelchairs can be boarded and then checked, or checked at the gate. Power wheelchairs are placed in the cargo compartment and require approval of the battery.  Airlines may require or recommend advance notice and written instructions on how to transport or disassemble the wheelchair.  It is recommended to remove and store any parts that are easily damaged or lost, such as control modules and electronics, separately.7

Cost and insurance coverage:

Cost may dictate the wheelchair prescription to some extent. Documentation of deficits and needs for the mobility device can be very specific. Insurance companies may require a detailed letter of medical necessity, including line-item justification for each of the recommended components, and how the wheelchair will help facilitate basic and instrumental ADLs. Often insurance policies dictate other things, including the length of time between wheelchairs (typically five years) or the type of wheelchair approved. For example, some insurers will not pay for both a manual and a power wheelchair, so patients with a progressive disease may have to choose based on future functional expectations rather than current needs.  Given this complexity, evaluation by a multidisciplinary specialty seating and wheelchair clinic is recommended.  Providers may include physiatrists, occupational and physical therapists, and wheelchair suppliers.  Expectations should also be managed on a timeline toward receiving a new customized wheelchair, which may take months until delivery.

According to CMS, the improper payment rate for power mobility devices was 46.3% in 2017, projected at $3.7 million of improper payments.13 The most common reasons for improper payments were insufficient documentation and medical necessity errors14.

The importance of cost and insurance is highlighted by research showing a disparity in the SCI patient population in providing the appropriate manual wheelchair, which is a lightweight and customizable wheelchair.12  Minority groups and those with low income, Medicare/Medicaid insurance or low education were more likely to receive a standard wheelchair rather than a customizable wheelchair. Similarly, Groah et. al performed another study on wheelchair accessibility for SCI patients and demonstrated that patients with private insurance were most likely to have a customizable wheelchair whereas self-pay patients were the least likely15.

Medicare has specific guidelines that apply to the prescription of manual and power mobility, which are considered Mobility Assistive Equipment (MAE), and are covered under the Medicare Part B DME benefit. See the “National Coverage Determination for Mobility Assistive Equipment” at CMS.gov for details (https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=219&ncdver=2&NCAId=143&ver=25&NcaName=Mobility+Assistive+Equipment&bc=BEAAAAAAEAAA&)16.

Under Medicare, to qualify for a manual wheelchair, the patient must meet the following criteria. Of note, Medicare requires that the manual wheelchair be necessary to complete ADLs inside the house and does not cover mobility equipment that is only used outside of the house.

  1. Has a mobility limitation that significantly impairs his/her ability to participate in 1 or more mobility-related activities of daily living (MRADL) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A “mobility limitation” includes being unable to perform the MRADL entirely, within a reasonable time frame, or places the patient at higher risk of morbidity or mortality to attempt MRADLs.
  2. Other comorbidities (i.e. vision, cognition) do not limit patient’s ability to use equipment to participate in MRADLs.
  3. If limitations above exist, can they be ameliorated or compensated such that the additional provision of equipment will be expected to improve the beneficiary’s ability to perform or obtain assistance for MRADLs.
  4. Patient or caregiver has not expressed unwillingness to use chair.
  5. Cannot be resolved with a cane or walker
  6. Patient’s home has adequate access and maneuverability.
  7. Use of chair will improve MRADLs and patient will use on a regular basis.
  8. Patient has sufficient capabilities to self-propel the chair during a typical day (for example, adequate cognition, vision, and upper extremity function).
  9. Patient has caregiver who is willing and able to assist with chair.

To qualify for a power mobility device (PMD) including scooter or power wheelchair, the patient must meet all the below13:

  1. Has a mobility limitation that significantly impairs his/her ability to participate in 1 or more mobility-related activities of daily living (MRADLs).
  2. Cannot be resolved with a cane or walker.
  3. Does not have sufficient upper extremity function (due to pain, deformity, absence of limbs, limited strength, endurance, range of motion or coordination) to self-propel a manual wheelchair in the home to perform MRADLs.

To qualify for a scooter, additional criteria:

  1. Must be able to safely transfer to/from scooter, operate the tiller, and maintain postural stability.
  2. Has mental and physical capability for safe use in the home
  3. Weight within the weight capacity of the scooter
  4. Home has adequate access, maneuvering space, and surfaces for operation
  5. Using a scooter will significantly improve ability to perform MRADLs
  6. Not expressed an unwillingness to use the PMD

To qualify for a power wheelchair, additional criteria:

  • Does not meet criteria for a scooter
  • Has mental and physical capability for safe use in the home, or caregiver is available and willing to operate
  • Weight within the weight capacity of the power wheelchair
  • Home has adequate access, maneuvering space, and surfaces for operation
  • Using a power wheelchair will significantly improve ability to perform MRADLs
  • Not expressed an unwillingness to use the PMD

Additionally, the provider must conduct a face-to-face examination, specifically described as a “mobility examination,” and document the examination, before writing the prescription (known as the 7-element order).  The report and order should go to the supplier within 45 days of the examination.  The device must be delivered within 120 days of the examination.17

The face-to-face examination report should address the following:

The written prescription (7-element order) requires:

  1. Patient’s name
  2. Date of patient’s face-to-face examination
  3. Pertinent diagnoses/conditions that relate to the need for device
  4. Description of item ordered
  5. Length of need
  6. Treating physician’s signature
  7. Date of physician’s signature

Cutting Edge/Unique Concepts/Emerging Issues

Recent advances and future directions:

Many recent and proposed innovations in wheelchair design revolve around advances in technology.  These innovations are incredibly varied in scope, design, and effectiveness, but all attempt to improve on the many challenges that wheelchair users still find in daily use.  Many users still find wheelchairs difficult or impossible to use for daily activities and 40% report difficulty or impossibility with steering or maneuvering tasks.  Many people, including those with vision impairments, cognitive impairments, tremors, deformities, and impaired upper body and head control, are unable to control a power wheelchair by conventional methods.18  Safety remains a concern, with more than 100,000 wheelchair related injuries treated in US emergency departments in 2003. The majority of these injuries were caused by tips or falls and were more likely to occur in homes or hospitals in adults.19 Injuries commonly occur during transfers or are related to loss of traction or loss of stability, since wheelchairs are primarily designed for indoor use.20 Most children’s wheelchair injuries occurred outside of the home nearby stairs, ramps, or curbs21. Other injuries occur in the setting of wheelchair breakdown (i.e. component and engineering failures).  Having a wheelchair less prone to failure is thus much safer (and may be worth a potential higher cost).

Examples of recent advances:

  • Improving safety and mobility – development of robotic wheelchairs that have selectable drive wheel location (rear/mid/front), self-leveling, curb climbing, traction control, two-wheel balance, stair climbing technology, and/or a wheelchair mounted robotic assisted transfer device.19,20
  • Expanding control devices – gaze-driven maneuverability; wearable orthotic control interface as opposed to a wheelchair mounted control device; voice control; LED screens; ergonomic joystick controls22; facial expression or body gesture control.23,24
  • Different materials/composition: 3D-printed carbon fiber wheelchairs that are lighter in weight, thus allowing for easier transportation
  • Speech generating devices
  • “Smart” wheelchair – incorporating multiple functions or technologies on one device. New devices and functions may include laser range finders, infrared or ultrasonic proximity sensors, and GPS/navigation controllers for mapping, localization, obstacle detection and cliff sensors; line or wall following; door passage; path planning, semi-autonomous or autonomous control; camera for telehealth, communication with family and health care providers, or medical alert system; integrated controllers for household appliances and computer access.18,24,25, Example: self-driving wheelchair being developed by Guru IoT in South Korea

Recent legislation issues:

In November 2014, CMS announced it would use information from the Medicare DMEPOS Competitive Bid Program to adjust the fee schedule for competitively bid items, including wheelchair accessories. The intention was to reduce insurance fraud and abuse. The bid information was drawn largely from standard wheelchair accessories and would be used to reduce payments on complex rehab wheelchair accessories, even though these accessories are vastly different in purpose and actual costs.  This policy would drastically underestimate the costs for complex rehab technology, and thereby limit access of this equipment to the vulnerable population that requires it.  This policy went into effect January 1, 2017. Legislation has been introduced in the House of Representatives and Senate to clarify the distinction between complex rehab technology and standard wheelchairs. The Protecting Access to Wheelchairs Act, which excludes wheelchairs from Medicare’s competitive acquisition program, was introduced to the House of Representatives, but no action has been taken on it yet26.

For more information, visit:

Access2CRT.org: www.access2crt.org/

Protect My Mobility: www.protectmymobility.org

Gaps in Knowledge/Evidence Base

Current gaps in knowledge include reliable ways to measure success and outcomes of these assistive devices. As mentioned previously, few formal assessment tools exist, so usually a candid conversation between provider and patient is used to assess outcomes. It is also difficult to assess the efficacy of one device (i.e. power wheelchair) compared to another (i.e. scooter), as randomized trials would be unethical. Furthermore, there are gaps in the knowledge regarding larger social or ethnic implications of wheelchairs, as demonstrated by disparities in access based on socioeconomic status or ethnic group.


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Original Version of the Topic

Susan V. Garstang, MD, Rana Rand, DO. Wheelchair and power mobility. 10/22/2013.

Previous Revison(s) of the Topic

Phil Chen, MD, Gianna Rodriguez MD. Wheelchair and power mobility. 3/23/2017.

Author Disclosure

Jeremy Roberts, MD
Nothing to Disclose

Jennifer Tram, BS
Nothing to Disclose

Hana Azizi, MD
Nothing to Disclose