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Wheeled Mobility and Seating Equipment

Pushrim-Activated Power-Assist Wheelchairs

For many years, there were three main types of wheelchairs available to those individuals with disabilities: manual wheelchairs, scooters and electric powered wheelchairs. Pushrim-activated power-assist wheelchairs (PAPAW) have become an option for wheelchair users. The PAPAW is a combination of a manual wheelchair and electric powered wheelchair where a motor is linked to the pushrim by way of the rear hub to reduce the effort required to propel.

Author Year

Research Design

Total Sample Size

Methods Outcome
Kloosterman et al. 2013


Systematic Review of published studies between 1980-2012


Method: Studies were included if they investigated the effect of power-assisted wheel-chair propulsion on human functioning compared to hand-rim or powered wheelchair propulsion; was a clinical trial or (randomized) controlled trial; was published as a full-length paper in a peer-reviewed journal in the English language.

Databases: The Cochrane Library, REHABDATA, CIRRIE and CINAHL.

Level of evidence:

15 crossover trials were assessed for their methodological quality using the ‘Checklist for Measuring Quality’ of Downs and Black Maximum attainable score=32


1.     To examine the current knowledge about transition from a hand-rim or powered wheelchair to a power-assisted wheelchair.

1.     The Downs and Black score assigned to all studies ranged between 9-15 points out of the maximum score of 32. All compared power-assisted to hand-rim or powered wheelchair use.

Results from quantitative analysis:

2.     Movement analysis of the arm during power-assisted propulsion compared to hand-rim propulsion was found to be significantly associated with a decrease in wrist ulnar-radial deviation and flexion-extension and decreased, flexion-extension and internal-external rotation in the shoulder. There was no significant association between either type of propulsion and shoulder abduction.

3.     Healthy populations found the hand-rim wheelchair more effective for tasks requiring greater control, whereas power-assisted wheelchair was preferred for easier tasks.

4.     Power-assisted wheelchairs were more preferred for activities within a confined space (or indoors) whereas powered wheelchairs were preferable for outdoor activities.

5.     There were no significant differences found for the association between wheelchair type (power-assisted, hand-rim or powered) and activity social participation, and psychological outcomes, within a home environment.

Results from the qualitative analysis:

6.     Most participants experienced increase ease of propulsion with a power-assisted wheelchair;

7.     Most rated power-assisted prolusion on level and inclines and carpet as (very) easy compared to hand-rim wheelchair propulsion.

8.     Some limitations were that power-assisted wheelchair in confined spaces were difficult to manoeuvre, car transfer from power-assisted WC wheels can be difficult.

9.     Other positive experiences were accessibility to new and different activities, and more independence.

Giesbrecht et al. 2009





Population: Age Range: 33-63 yr; Gender: males=6, females=2.

Intervention: Participants were randomly assigned use of a pushrim-activated power-assisted wheelchairs (PAPAW) or their own power wheelchair (PWC) for 3 wk and then crossed over to the alternative for 3 wk.

Outcome Measures: Activity Level: Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST, Functioning Every day with a Wheelchair (FEW), Psychosocial Impact of Assistive Devices Scale (PIADS); Participation Level: Canadian Occupational Performance Measure (COPM).

1.     Temporal Outcomes:

·       Mean hr per day spent in PAPAW (5.5 hr, SD=3.63) and PWC (6.1 hr, SD=5.36) and not significantly different (t(7)=-0.33, p=0.75);

·       Mean time spent per day in any wheelchair (manual and power wheelchair) was 8.83 hr (SD=5.34) and 9.17hr (SD=5.83) for the PAPAW and PWC blocks; not significantly different (t(7)=-0.54, p=0.60);

·       Total number of hr per week participating in identified occupations (56.1, SD=52.0; 62.8, SD=42.6) and not significantly different between PAPAW and PWC blocks (t(7)=-0.33, p=0.75);

2.     Outcome Measures at Activity Level (Quest, FEW, PIADS):

·       No identified difference identified between PAPAW and PWC on Quest Device subscale median (range) PAPAW score 3.8 (3.0-4.5) versus3.8 (1.9-5.0); p=0.945;

·       PIADS Self-Esteem subscale demonstrated a statistically significant difference with PWC rated higher median (range) PAPAW score 1.5 (-4-7) versus median (range) PWC score 7.5 (-2-18); p=0.016.

3.     Outcome Measure at Participation Level (COPM): Performance Component: no statistically significant difference found median PAPAW score 6.5 (4.0-9.0) versus median PWC score 8.2 (4.3-10.0); p=0.195

4.     Satisfaction Component: no statistically significant difference found median PAPAW score 7.2 (2.7-8.4) versus median PWC score 8.2 (2.3 -10.0); p=0.469.

Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data.

Nash et al. 2008





Population: Mean age: 39.1 yr; Gender: males=18, females=0; Level of injury: paraplegia=12, tetraplegia=6; Severity of injury: complete=18.

Intervention: Study participants were asked to complete five testing sessions during which they were asked to propel their chairs randomly on either their own wheels or the pushrim-activated power-assisted wheelchairs (PAPAW) wheels. Subjects performed each test twice.

Outcome Measures: Oxygen consumption, Distance, Energy cost, Ratings of perceived exertion (RPE).

1.     6 min steady state test sessions; Oxygen Uptake; VO2 significant effects found for group (F1.32=17.2, p<0.001), time F3.96=37.6, p<0.001) and group x time interaction (F3.96=11.2, p<0.001); significant increases at each time point between 0 and 6 for paraplegia, not for tetraplegia.

2.     Distance propelled: significant effect for group (F1.32=50.3, p<0.001), type of wheel (F1.32=27.3, p<0.001), time (F3.96=247.5, p<0.001) and group interaction effect (F3.96=14.7, p<0.001) with individuals with paraplegia traveling farther than tetraplegia and PAPAW traveling farther than traditional push wheels.

3.     Energy Costs: significant effort for wheel was found for energy cost (F1.32=9.7, p<0.01) with the traditional wheels requiring greater energy costs than PAPAW.

4.     Perceived Exertion: time was the only significant effect observed (F3.96=52.3, p<0.001) with score getting significantly higher at each stage for all subjects.

5.     Twelve Minute Test Sessions: Oxygen Uptake: Vo2 significant effects were found for group (F1.32=14.8, p=0.001), time (F6.192=18.0,p<0.001) and the group x time interaction (F6.192=7.5, p<0.001), significant increases at each time point between 0 and 12 for paraplegia, not tetraplegia.

6.     Distance Propelled: significant effects found for group (F1.32=59.6,p<0.001), type of wheel (F1.32=66.9, p<0.001), time (F6.192=216.5, p<0.001) the group x time interaction (F6.192=22.3, p<0.001) and wheel x time interaction (F6.192=25.8, p<0.001) with persons with paraplegia travelling farther than tetraplegia and PAPAW travelling farther than regular wheels, magnitude of change greater in persons with paraplegia and when using PAPAW.

7.     Energy Costs: significant effect for type of wheel (f1.32=20.4, p<0.001) with traditional wheels requiring higher energy cost than PAPAW.

8.     Perceived Exertion: RPE, time (F6.192=89.6; p<0.001) and wheel x time interaction (F6.192=2.2; p<0.05) were different with scores rated significantly higher at each stage across all subjects and in overall score for PAPAW being lower than traditional wheels; significant increase in RPE between time 0 and 12 for both wheels and PAPAWs with change greater in customary wheels at time 2, 4, and 12.

Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data.

Guillon et al. 2015





Population: Mean age: 38.8 yr; Gender: males =31, females=21.

Intervention: Individuals were evaluated on the use of manual wheelchairs and three pushrim-activated power-assisted wheelchairs (PAPAW): Servomatic A, Servomatic B and E-motion. The study was conducted in three phases: phase 1 consisted of participants propelling all the wheelchairs on a dynamometer (n=10), phase 2 consisted of using wheelchairs on indoor and outdoor courses (n=46), while phase 3 evaluated participants’ ability to transfer themselves and their wheelchairs into and out of cars (n=10). Participants used all wheelchairs for each phase, the order of wheelchair use was randomized for each participant.

Outcome Measures: Oxygen consumption per unit time (VO2), Heart rate, Completion time, Handrim push frequency, Patient satisfaction.

1.     All PAPAW showed a significantly greater decrease in oxygen consumption and heart rate during phase 1 compared to manual wheelchairs (p<0.005). There were however no significant differences between the three PAPAW groups.

2.     During the outdoor tests, a MANOVA revealed statistically significant effects of wheelchair type (p<0.0001), lesion level (p<0.0001), and interaction between wheelchair type and lesion level (p<0.0004) on several dependent variables (completion time, handrim push frequency, maximal heart rate and patient satisfaction).

3.     For the indoor tests, a MANOVA revealed statistically significant effects of wheelchair type (p<0.0001) on completion time, handrim push frequency and patient satisfaction.

4.     More participants required help for transfers with PAPAW compared to manual wheelchairs (p=0.04).

Ding et al. 2008




Population: Mean age: 38.3 yr. Gender: NR; Level of severity: tetraplegia=15; Mean time since injury: 15.8 yr.

Intervention: Individuals used their own personal wheelchairs for 2wk and then pushrim-activated power-assisted wheelchairs (PAPAW) for 2wk. Mobility levels with both wheelchairs were recorded by a datalogger.

Outcome Measures: (Primary): Daily distance traveled, Average speed, Accumulated driving (movement) time, Number of starts/stops, Maximum period of continuous movement, Maximum distance of continuous movement. (Secondary variables): Percentage of time between 0.5m/s, Percentage of time between 0.5m/s and 1.0m/s, Percentage of time over 1.0m/s, Psychosocial Impact of Assistive Devices Scale (PIADS).

1.     No significant differences were found for the distance traveled with both wheelchairs (p=0.009).

2.     There was a statistically significant difference found between PAPAW and personal manual wheelchairs for the speed traveled (PAPAW: average speed=0.74±0.31 m/s; Personal: average speed=0.60±0.23 m/s, p=0.03).

3.     Participants traveled similar distances in the PAPAW trial and the own chair trial (p=0.16).

4.     Results of secondary mobility variables were the following: Number of starts/stops (per 1000 m): [PAPAW: 65.4±25.7 m; Personal wheelchair: 78.3±21.8 m; Own Chair Trial (2 wk) Personal wheelchair: 75.2±22.7 m]. Maximum period of continuous movement (min): [PAPAW: 3.0±2.4 min; Personal Wheelchair: 2.1±2.7 min; Own Chair Trial (2wk) Personal Wheelchair: 3.3±4.6 min], Maximum distance of continuous movement (m): [PAPAW: 229.2±289.4 m; 135.4±248.7 m; Own Chair Trial (2wk) Personal Wheelchair: 229.8±409.3 m).

5.     Self-perceived PIADS assessment revealed no significant differences for ratings of adaptability, competency, and self-esteem between the PAPAW and the traditional manual wheelchair (p=0.18, p=0.07 and p=0.09, respectively).

Finley et al. 2007




Population: Mean age: 46 yr; Gender: males=9, females=8; Injury etiology: SCI=11, spina bifida=1, polio=1, stroke=1, ataxia=1, spinal stenosis=1, rheumatoid arthritis=1.

Intervention: Individuals used a manual 2-speed geared wheelchair wheel over five months (MAGICWheels intervention).

Outcome Measures: The Wheelchair Users Shoulder Pain Index (WUSPI); Wheelchair Users Functional Assessment (WUFA); Timed hill climb test with rating of perceived exertion (RPE).

1.     There was a statistically significant reduction in WUSPI (shoulder pain score) with the MAGICWheels intervention at wk 2 (p=0.0444); these results remained statistically significantly different from baseline until wk 16 (p=0.015), however not at wk 20 (p=0.062).

2.     Post-hoc correlation analysis revealed no significant relationship between duration of wheelchair use and pain reduction for any wks of the MAGICWheels intervention (p>0.05).

3.     After the 5-mo period, there was no significant difference in WUFA scores (p>0.05).

Haubert et al. 2005




Population: Mean age: 48 yr; Gender: males=5, females=0; Injury etiology: tetraplegia=4, paraplegia=1; Mean time since injury: NR.

Intervention: To compare the propulsion characteristics between a standard manual WC and each of three pushrim-activated power-assisted wheelchairs (PAPAW): iGLIDE Xtender with a 1.5X power-assist; an e-motion with settings adjusted to mid-sensitivity; and maximum power-assist.

Outcome Measures: Energy Expenditure (average heart rate and O2 consumption); Average velocity (m/min±1SD); Average cadence (cycles/min±SD).

1.     Compared to standard WC propulsion, during iGLIDE propulsion, velocity increased for two subjects due to increased cycle length and cadence (mean increases: 15% and 28%), respectively. Average velocity decreased in the iGLIDE for three subjects as a result of decreased cadence and cycle length (mean decreases=19%, 46%, 33%, respectively).

2.     Compared to standard WC propulsion, during Xtender propulsion, velocity increased for 3/5 participants by 20%, 16% and 40%. Velocity increased from increased cadence for one subject by12% and decreased by 7% for another subject, from decreased cadence.

3.     Compared to standard WC propulsion, during propulsion, velocity increased by 22% from increased cycle length and cadence for one subject. For another, it slightly increased by 3% from increased cycle length; and further decreased for three subjects by 5%, 7% (from decreased cadence) and 5% (from reduced cycle length), respectively.

4.     Compared to standard WC propulsion, three subjects were found to have a decreased average O2 heart rate and consumption

5.     An increase in O2 consumption during PAPAW propulsion was observed during iGLIDE propulsion by 5% for one subject; another subject by 18% for Xtender; and by 25% for propulsion.

6.     On average, the Oconsumption cost decreased for all subjects during Xtender and propulsion in each PAPAW.

7.     On average, there was an increase in Ocost for two subjects with respect to propulsion of iGLIDE, and similar Ocosts as standard WC for another.

Algood et al. 2004




Population: Age range: 27-52 yr; Gender: males=12, females=3; Weight range: 45-116 kg; Height range: 152-193 cm; Level of injury: tetraplegia=15; Chronicity: chronic.

Intervention: Propulsion of personal wheelchair and pushrim-activated power-assisted wheelchairs (PAPAW) in dynamometer at 0.9 m/s for 3 min/trial, with three difference resistances (10 W, 12 W, 14 W).

Outcome Measures: Mean steady state oxygen consumption, Ventilation, Heart rate, Mean stroke frequency, Maximum upper extremity range of motion (ROM).

1.      Subjects had a significant reduction in ventilation and oxygen consumption in all PAPAW trials compared to manual wheelchair trials (p<0.05).

2.      When using the PAPAW, heart rate only decreased in the 14 W condition (p<0.001) and stroke frequency only decreased in the 10W and 12W conditions (p=0.001).

3.      When using the PAPAW, horizontal flexion/extension, shoulder flexion/extension, internal/external rotation and wrist ulnar and radial deviation ROMs were all significantly decreased in all weight resistance conditions (p<0.05).

4.      Forearm supination/pronation ROM was significantly decreased in the 12 W and 14 W trials (p<0.01) when using the PAPAW. Elbow and wrist extension/flexion ROM were also significantly reduced in the 14 W trials (p<0.05).

Fitzgerald et al. 2003




Population: Mean age: 42.1 yr; Gender: males=5, females=2; Level of injury: paraplegia=7; Time since injury range: 5-22 yr; Chronicity=chronic.

Intervention: Manual wheelchair and pushrim-activated power-assisted wheelchairs (PAPAW) wheelchair.

Outcome Measures: Distance traveled and velocity-Data logger; Qualitative information-Visual Analog Scale.

1.      No significant differences were found between the subject’s personal wheelchair and the PAPAW for distance or velocity; however, some trends were noted.

2.      Subjects would use the PAPAW more often upon leaving their homes. Subjects seemed to like the PAPAW’s ease of use (85%), quick travel abilities in short or longer distances (29%) and the ability to climb hills easier (43%). They also rated the PAPAW as comfortable and easier to propel.

3.      More activities were accomplished in a day when using the PAPAW, as the subjects felt it was faster than their power wheelchair and it supplied relief when tired.

4.      With the PAPAW, subjects did not like battery location, height and weight of chair, lack of control over power levels and transportability.

Corfman et al. 2003




Population: Mean age: 34.5 yr; Gender: males=6, females=4; Level of injury: paraplegia=18; Chronicity=chronic.

Intervention: Propulsion of a Quickie 2 manual wheelchair configured as a pushrim-activated power-assisted wheelchairs (PAPAW) and personal wheelchair on a dynamometer at 2 speeds and 3 resistance levels for 3 min per trial (minimal-0.9 m/s and 10 W; 1.8 m/s and 25 W; slight-0.9 m/s and 12 W; 1.8 m/s and 25 W; moderate-0.9 m/s and 14 W).

Outcome Measures: Stroke pattern, Stroke frequency, Range of motion (ROM)-shoulder flexion/extension, abduction/adduction, internal/external rotation, horizontal flexion/extension-elbow flexion/extension, supination/pronation, ulnar/radial deviation.

1.      No stroke pattern difference was found between the two wheelchairs.

2.      Stroke frequency was different when comparing the two wheelchairs; however, this difference was dependent on speed (0.9 m/s or 1.8 m/s).

3.      During both of the slight trials and 0.9m/s moderate trial, shoulder flexion/extension ROM was decreased (p<0.05). During the 0.9m/s slight trial and 1.8 m/s normal trial, elbow and wrist flexion/extension ROM was decreased (p<0.05). Also, the wrist ulnar/radial deviation ROM was decreased during the 0.9m/s slight and moderate trials (p<0.05).

4.      With the exception of shoulder internal/external rotation, the PAPAW was accountable for reducing ROM values for all dependent variables.

Cooper et al. 2001




PopulationPhase 2: Mean age: 35 yr; Gender: males=6, females=4; Level of injury: paraplegia=9, MS=1; Mean time since injury: 13 yr. Phase 3: Mean age: 45.2 yr; Gender: males=6, females=4; Level of injury: paraplegia=9, multiple sclerosis=1.
Intervention: Phase 2-Propulsion of personal chair and pushrim-activated power-assisted wheelchairs (PAPAW) on dynamometer. Phase 3-Propulsion of personal chair and PAPAW through standardized activities of daily living obstacle course three times.Outcome Measures: Phase 2-Oxygen consumption, Ventilation, Heart rate. Phase 3-Performance on course; Completion time, Self ratings of comfort and ergonomics, Stroke frequency, Heart rate.
Phase 2:

1.      Subjects using the PAPAW had lower oxygen consumption (VO2 mL/min, and VO2 mL/kg x min, p<0.001) and heart rate (p<0.05 in two conditions) when compared to their manual wheelchair use.

2.      Oxygen consumption and heart rate, but not ventilation, were significantly different when comparing chairs and speed (p<0.001).

 Phase 3:

3.      The PAPAW had a higher ergonomic evaluation than the manual wheelchair (p<0.01).

4.      Subjects had faster completion times of the Activities of Daily Living (ADL) course (p=0.01) and had less difficulty over the large speed bump between trial 1 and 3 (p=0.02), when using the PAPAW as compared to the manual wheelchair.

5.      The PAPAW had lower ratings on car transfer tasks of taking wheels off (p=0.004) and putting wheels back on (p=0.001).

Algood et al. 2005




Population: Age range: 20-53 yr; Gender: males=11, females=4; Weight range: 45-114 kg; Height range: 152-193 cm; Level of injury: tetraplegia=15; Time since injury range: 0.8-30.0 yr; Chronicity: sub-acute-chronic.

Intervention: An obstacle course containing activities of daily life. Subjects used both their personal wheelchair and a pushrim-activated power-assisted wheelchairs (PAPAW) three times each.

Outcome Measures: Heart rate, Completion time, Visual analog scale (VAS), Amount of assistance required.

1.      It was significantly easier for subjects to complete the obstacle course with the PAPAW, as compared to their own wheelchair (p<0.001). This was most apparent with the carpet, dimple strips, ramp incline and up curb cut obstacles (p<0.001).

2.      Completion time of the course, response to ergonomic questions and amount of assistance needed did not differ between wheelchairs.

3.      Mean heart rate was significantly lower in all three PAPAW trials when compared to the three personal wheelchair trials (p=0.015, p=0.001, p=0.003).

Summarized Level 5 Evidence Studies

The following level 5 evidence studies have been reviewed, and the overarching findings from the studies are highlighted in this section. As noted at the start of this chapter, these types of studies are not included in the discussion or in the conclusions.

In a qualitative study, Giacobbi et al. (2010) gathered reported experiences from participants before, during, and after use with a power assist wheelchair (PAW). 95 %of participants reported that PAWs allowed greater access to diverse terrains that included sand, gravel and grass and made wheeling up inclines easier. 80% of participants reported general decreases in fatigue after using the PAWs. Participants reported that PAWs helped to improve mood and help with independence with respect to mobility. 65% of participants (13/20) reported that the use of PAWs was linked to participation in novel activities or those that were “out of the ordinary”. Participants expressed that some of these were previous activities they couldn’t participate in, for example, going to the flea market and zooming around, or playing ball in the yard with their dog.


There were three randomized control studies that explored PAPAW use. Giesbrecht et al. (2009) studied eight participants (mixed diagnoses) who used both a manual wheelchair and a power mobility device (dual users) in their everyday activities in determining if a PAPAW would be an alternative to a power wheelchair (PWC) for community-based activities. The study results suggested that after introducing PAPAW, study subjects remained as active in their community and spent similar amount of time using the PAPAW instead of their PWC. It was interesting to note that on the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) Device subscale (outcome measure addressing activity level) the study participants rated four device subscale items higher for PAPAW use (weight, comfortable, dimensions, ease in adjusting) and four items higher for PWC use (durability, easy to use, safe and secure and effective). Study subjects identified that the PWC was preferred for outdoor activities and the PAPAW for tasks performed in a confined space. Only the self-esteem subscale (relates to emotional response and self-propulsion) on the Psychosocial Impact of Assistive Devices Scale (PIADS) was statistically significant between PWC and the PAPAW.

In the second RCT, Nash et al. (2008) tested the effects of PAPAW with respect to the energy needed and perceived effort required when wheeling a manual wheelchair for six minutes at a steady state and for twelve minutes with resisted wheeling at the study subject’s greatest attainable speed. During the six-minute steady state and 12-minute resistive propulsion trials there was a significant increase in oxygen uptake (VO2) at each time point for persons with paraplegia only. In addition, individuals with paraplegia travelled significantly farther than individuals with tetraplegia when using the PAPAW and both groups travelled farther with PAPAW than when using traditional wheels. Traditional wheels required greater energy cost than PAPAW and this increased the perceived exertion across all study subjects as the time component increased during the trials.

In the third RCT, Guillon et al. (2015) compared three different PAPAW (Servomatic A & B, and E-motion) to standard manual wheelchairs in a three phase study assessing wheelchair propulsion, indoor/outdoor use and ease of transferability in vehicles. Use of PAPAW resulted in greater decreases in oxygen consumption and heart rate compared to manual wheelchairs. But ease of transferability was greater when participants used manual wheelchairs compared to PAPAW. For the indoor and outdoor tests, the Servomatic PAPAW had better performance on completion time, pushrim frequency, and patient satisfaction compared to the E-motion PAPAW.

Corfman et al. (2003) examined the efficacy of the PAPAW in the reduction of upper extremity ROM and stroke frequency with nine individuals with paraplegia. When using the PAPAW upper extremity ROM was significantly reduced. The use of the PAPAW did not affect propulsion frequency. They suggest that the use of this device may reduce the frequency of upper limb injuries and allow an individual to use a manual wheelchair for a longer period of time.

Algood et al. (2005) compared the ability individuals to complete an obstacle course using a PAPAW and their own manual wheelchair. It was significantly easier for the subjects to propel on carpet, dimple strips, up a ramp as well as up curbs when using a PAPAW. Also, the mean heart rate was significantly lower. However, there was no significant difference in the time to complete the course, response to ergonomic questions or the amount of assistance required.

Cooper et al. (2001) compared the PAPAW to the subject’s own wheelchair on a dynamometer and also through an obstacle course. On the dynamometer, subjects had lower oxygen consumption and heart rate when using the PAPAW as compared to their own manual wheelchair. Oxygen consumption and heart rate, but not ventilation was significantly different when comparing chairs and speed. On the obstacle course the PAPAW had a higher ergonomic evaluation than the manual wheelchair. Subjects had faster completion times with the PAPAW and less difficulty going over the speed bump. The PAPAW had lower ratings on car transfer tasks of taking wheels off and putting them back on.

Algood et al. (2004) investigated the differences in metabolic demands, stroke frequency and upper extremity ROM when propelling the PAPAW as compared to a regular manual wheelchair. Individuals propelled their own manual wheelchair and a PAPAW through three different resistances on a wheelchair dynamometer. Ventilation, oxygen consumption and upper extremity ROM was significantly reduced when using the PAPAW. Stroke frequency was reduced at low resistances. They also found that the PAPAW has the potential to reduce metabolic energy expenditure.

Fitzgerald et al. (2003) followed individuals for a period of four weeks, two weeks using a PAPAW and two using their own personal wheelchair. No significant differences were found between the user’s own wheelchair and the PAPAW for average and total distance travelled, velocity, or the number of times leaving the house. However, the subjects reported that they were more apt to use the PAPAW when leaving their house. The subjects also reported that the PAPAW provided relief when fatigued and that the wheelchair went faster (perception) resulting in accomplishing more in the day. The subjects rated the PAPAW with higher comfort and easier propulsion as compared to their own wheelchair.


There is level 4 evidence (from one pre-post test study: Corfman et al. 2003) that the use of a PAPAW will reduce upper extremity ROM in individuals with paraplegia during wheelchair propulsion.

There is level 4 evidence (from three pre-post test studies: Algood et al. 2005; Cooper et al. 2001; Fitzgerald et al. 2003) that use of a PAPAW may improve the ability of individuals with tetraplegia to use their wheelchair in a variety of environments and for typical activities.

There is level 4 evidence (from one pre-post test study: Cooper et al. 2001) that the use of a PAPAW may reduce metabolic energy costs for individuals with paraplegia during propulsion and has higher ergonomic rating by users.

There is level 4 evidence (from one pre-post study: Algood et al. 2004) that the PAPAW reduces upper extremity ROM in individuals with tetraplegia during wheelchair propulsion. Metabolic energy expenditure and stroke frequency may be reduced.

There is level 2 evidence (from one low level RCT study: Guillon et al. 2015) that PAPAW results in decreased oxygen consumption and heart rate compared to manual wheelchairs.

There is level 1b evidence (from one randomized controlled trial: Nash et al. 2008) that the use of PAPAW allows individuals with a spinal cord injury (paraplegia and tetraplegia levels) who have long standing shoulder pain to propel their wheelchair further while decreasing energy costs and perceived exertion.

There is level 1b evidence (from one randomized controlled trial: Giesbrecht et al. 2009) that for individuals requiring power mobility, the pushrim-activated, power assisted wheelchair may provide an alternative to power wheelchair use.

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