Key Points

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Wheelchair propulsion

  • The evidence suggests that stroke pattern use varies based on individual preference and the environmental demands with some stroke patterns being more effective to achieve specific outcomes.
  • The evidence supports that to avoid accumulating shoulder impingement stresses proper technique must be considered based on a combination of kinematics (e.g., contact angle, stroke frequency, movement patterns at each joint), stroke pattern, wheelchair fit and set up.
  • Neck, trunk, scapular, clavicle, elbow, wrist and shoulder kinetics and kinematics singly or cumulatively influence the efficacy of manual wheelchair propulsion therefore should all be considered in propulsion efficiency as well as in propulsion-related injuries, particularly if propulsion speed or surface slope increases.
  • The push and recovery phases of propulsion both need to be considered in relation to manual wheelchair propulsion as the kinetics and kinematics differ, and differ between people with paraplegia and tetraplegia, which therefore have implications for propulsion training in the clinical setting.
  • The following need to be considered in relation to propulsion and back support height; a) effect on propulsion cadence; b) amount of shoulder range of motion used and; c) the length of the push stroke (i.e., length between the start and end position of the hand on the rim).
  • Wheeling cross slope can negatively affect the cadence and power that is required for wheelchair propulsion.
  • The strength of specific shoulder and elbow muscles, and the ability to flex the trunk forward all affect the efficiency in performing advanced wheelchair skills particularly those associated with wheelies and caster pop-ups. Given the increased mechanical and muscular demands in these types of advanced skills, the quality of shoulder, elbow and trunk movements should be considered to balance protection of the upper extremity shoulder with being functional in the community.

Effect of wheelchair frame and/or set-up on propulsion

  • Manual wheelchairs with adjustable axle position appear to improve wheelchair propulsion and reduce the risk of upper extremity injury.
  • The use of lighter weight wheelchairs may improve propulsion efficiency in those with SCI particularly at the start of propulsion.
  • Body weight management is important in reducing the forces required to propel a wheelchair and reducing the risk of upper extremity injury.
  • There is insufficient evidence to determine if Spinergy wheels are more effective in reducing spasticity by absorbing vibration forces when wheeling than standard steel-spoked wheels.
  • Tires with less than 50% inflation causes an increase in energy expenditure.
  • Use of flexible or contoured handrims may reduce upper extremity strain thereby reducing discomfort and pain symptoms during wheelchair propulsion.
  • The use of power-activated power-assist wheelchairs (PAPAW) provide manual wheelchair users with paraplegia and tetraplegia with a less strenuous means of mobility, improve functional capabilities and reduce the risk of upper extremity injury.


Wheelchair training

  • Propulsion characteristics of contact angle, stroke frequency and peak force at the handrim, all noted to be important to maintaining upper extremity health during propulsion, can be positively affected through w/c propulsion training.
  • Clinicians should consider incorporating a multimedia approach, such as video and verbal instruction with observational feedback, into wheelchair propulsion training particularly for people who are new to w/c use.
  • Physical conditioning and strengthening of the upper extremity is important to the development of wheelchair propulsion capacity; it should begin at initial rehabilitation.

Wheelchair use

  • Wheelchair use varies between individuals, however daily propulsion distance is small amongst most users. Shoulder strength, the user’s environment, and age all contribute to propulsion distance amongst wheelchair users, these factors should be considered when developing rehabilitation plans for these individuals.
  • Many of the predictive risk factors for wheelchair related falls and resultant injuries are modifiable; therefore, considerations and education related to preventing falls should be included in wheelchair interventions.
  • Maintenance and repair issues arise frequently for people who use wheelchairs therefore are important considerations in the wheelchair service delivery process and the manufacturing process.
  • Optimizing the potential for satisfaction with wheelchair use requires consideration of the fit and function of the wheelchair during the service delivery process particularly for quality of life based activities such as leisure pursuits; satisfaction with the service delivery process requires timeliness throughout the wheelchair provision process.
  • There is good evidence that wheelchair skill training can improve skills in the short term and that video feedback produces similar results as conventional skill training.
  • There is evidence that propulsion skills are most commonly taught to wheelchair users during in-patient rehabilitation and that advanced w/c skills, particularly wheelie related skills, are not learned by most people.
  • The focus of wheelchair skills training during shortening rehabilitation stays should consider the person’s home and community environments and activities is needed as it is suggested that not all skills are essential to functioning in daily life.

Characteristics of power wheelchair use

  • Considerations for how individuals use power wheelchairs should include more than distance and speed travelled, indoor/outdoor use and wheelchair occupancy.
  • For the SCI population power wheelchair provision needs to include at a minimum customizable programmable control.
  • Consideration should be given to the potential provision of both power and manual wheelchairs to meet basic living needs for the SCI population.

Power wheelchair driving controls

  • There is limited evidence related to the benefit and use of conventional versus alternative driving controls.

Power positioning device use 

  • Patterns of use for power positioning devices are variable but typically in small ranges of amplitude, with the primary reasons for use being discomfort and rest.


  • Segway Personal Transporters may present an alternative form of mobility for individuals with SCI who are able to stand and walk short distances.

Pressure mapping used in SCI

  • Pressure mapping can be used to augment clinical decision-making related to pressure management.

Postural implications of Wheelchairs

  • Individual attention to spinal/pelvic posture and positioning for SCI clients is essential for appropriate wheelchair prescription and set-up.
  • Use of lateral trunk supports in specialized seating improve spinal alignment, reduce lumbar angles and reduce muscular effort for postural control.

Impact of equipment on functional tasks

  • The wheelchair user’s posture and functional performance have important implications on the selection of a wheelchair and seating equipment.

Cushion comparisons

  • No one cushion is suitable for all individuals with SCI.
  • Cushion selection should be based on a combination of pressure mapping results, clinical knowledge of prescriber, individual characteristics and preference.
  • More research is needed to see if decreasing ischial pressures or decreasing risk factors such as skin temperature via the use of specialty cushions will help
    prevent pressure ulcers post SCI.
  • Pressure mapping is a useful tool for comparing pressure redistribution characteristics of cushions for an individual but it needs to be a part of the full evaluation not the main part or only evaluation.
  • For wheelchairs users with pressure ulcers, screening and assessment of depressive symptoms should be conducted as this population is vulnerable to developing these.

Custom contoured cushions

  • Contoured foam cushions compared to flat foam cushions seem to provide a seat interface that reduces the damaging effects of external loading and tissue damage.

Changes in pressure during static sitting versus dynamic movement while sitting

  • Peak interface pressure is greater for dynamic movement in SCI subjects than static sitting but cumulative loading is comparable between dynamic and static loading for the SCI population.
  • Peak pressures appear to be located slightly anterior to the ischial tuberosities (IT).
  • The use and integration of forward reaching into daily life activities can be used as a means to promote regular pressure redistribution. Caution however is needed to ensure the movement is of adequate distance and duration to affect pressure management.

Position changes for managing sitting pressure/postural issues, fatigue and discomfort

  • Leaning forward at least 45° (elbows on knees position) or lateral trunk leaning to 15° reduces pressure and increases blood flow and tissue oxygenation at the sitting surface; it is important to be able toreturn to the original upright sitting position.
  • For most individuals with SCI, the use of a push-up/vertical lift is unlikely to be of sufficient duration to be beneficial for managing sitting pressure and has potential to contribute to repetitive strain injuries and a reduction of subacromial space.
  • The back support plays an important role in pressure management on the sitting surface.
  •  Backrest recline alone to 120° decreased average maximum pressures in the ischial tuberosity area but also causes the greatest ischial tuberosity shift (up to 6 cm). Further research on the effect of friction/shear on the sitting surface in relation to the ischial tuberosity shift is required to determine if there is benefit in using backrest recline alone.
  • There is an inverse relationship between tilt angle and pressure at the sitting surface. Significant pressure redistribution realized was variable by person but on average started around 30° of tilt with maximum tilt providing maximum pressure redistribution.
  • It cannot be assumed that a change in interface pressure through use of tilt/recline equates to an increase in blood flow at the ischial tuberosities (IT).
  • The variability in blood flow and interface pressure changes associated with tilt/recline, supports the need for an individualized approach to education around power positioning device use for pressure management.
  • The type and duration of position changes for pressure management must be individualized
  • More research is needed to determine the parameters of position changes in relation to interface pressure and blood flow at the sitting surface tissues to help prevent pressure ulcers post SCI.
  • While power positioning technology including combinations of tilt, recline and stand, offer many health-related benefits, individualized assessment and thorough consideration of contraindications are required to ensure safe and appropriate use.

Wheelchair provision

  • There is lower level evidence to suggest that people who receive specialized seating assessment and/or client-centred wheelchair interventions have better outcomes.