Wheelchair Usage

In the wheelchair usage section, the majority of studies are surveys, descriptive studies, or have used cross-sectional analysis to interpret results, therefore have a level 5 evidence rating. It is felt that these studies have novel and important observations to offer the reader; for these reasons they have been left in the body of this section and not summarized as in other sections. They are also included in the discussion and conclusion statements. Studies have explored different factors related to wheelchair use and participation and examined the gender differences in shoulder strength as it relates to propulsion and therefore wheelchair use.

Author YearCountry
Research Design
Total Sample Size
Methods Outcome
Karmarkar et al. 2011




Population: Mean age: 62.5 yr; Gender: males=37, females=2; Level of Injury: cervical=12, thoracic=11, lumbosacral=4, other=11; Mean time since injury: 29.4 yr.
 Participants’ wheelchairs were fitted with a customized data-logging device to measure mobility during the National Veterans Wheelchair Games (NVWG).
Outcome Measures:
 Wheelchair-related mobility variables.
1.   Both the manual wheelchair (MWC) and power wheelchair (PWC) participants had significantly higher mobility during the NVWG, compared to in their home and community, regarding distance traveled (MWC p<0.001, PWC p=0.004), wheelchair propulsion velocity (MWC p<0.001, PWC p=0.002), continuous wheelchair drive distance (MWC p<0.002, PWC p=0.006) continuous wheelchair drive time (MWC p<0.001, PWC p=0.005), number of stops every 500m (MWC p<0.001, PWC p=0.002).2.   There was no significant difference in MWC and PWC groups in number of events participated for all sports activities (p=0.12).
Tsai 2014


Case Series


Population: Mean age: 40.0 yr; Gender: males=2362, females=623; Severity of injury: AIS A/B=2529 C=457; Mean time since inury: 6 yr.Intervention: Data was gathered from the National Spinal Cord Injury Database (NSCID). Participation and employment status were assessed from follow up interviews. Initial interviews were conducted on SCI patients from 18 centers of the Model Spinal Cord Injury System in the US from 2004-2010.

Outcome Measures: Craig handicap assessment and reporting technique-short form questionnaire (CHART-SF) and employment status to measure social participation, and evaluate the association with type of mobility device used (manual w/c; externally powered wheelchair (i.e., power w/c, or power assist wheels) and driving vehicle).

1.     Positive correlations noted between using an externally powered wheelchair and age, age at injury, being Females, higher injury level and having an indwelling catheter.2.     Negative correlations were observed between using an external powered wheelchair and being employed, AIS A/B, upper limb strength, and FIM scores.

3.     Positive correlations were observed between using a modified vehicle and being employed, AIS A/B, upper limb strength, FIM scores, and years since injury.

4.     CHART-SF and likelihood of employment were negatively correlated with age, age at injury, using an external powered wheelchair, having a catheter indwelling in the bladder, and pain.

5.     CHART-SF and likelihood of employment were positively correlated with years since injury, using a modified vehicle, upper limb strength, using intermittent bladder catheterization, and FIM scores.

6.     CHART-SF and employment were positively correlated with using a modified vehicle compared to not possessing or driving a modified vehicle.

7.     Participants who used a modified vehicle had approximately: 2 days more out of home per wk, two more business associates, and 1 additional friend contacted at least once a mo compared to participants not possessing a modified vehicle.

Pettersson 2015




Population: Median Age: 64 yr; Gender: males=33, females=15; Level of injury: tetraplegia=26, paraplegia=22.Intervention: All participants were administered a Swedish aging with a spinal cord injury study (SASCIS) specific questionnaire.

Outcome Measures: SASCIS: Patient characteristics, Environmental barriers and accessibility component of the Housing Enabler assessment, Impact on participation and autonomy (IPA) assessment.

1.     Patients with powered mobility devices (PMD) used their device significantly more for outdoor and indoor use compared to just outdoor (p<0.0005).2.      Patients who used their PMD’s outdoors only had a significantly lower functional limitation due to a prevalence of reduced fine motor skills compared to those who used their PMD’s indoor and outdoor (p=0.009).

3.     Patients who used their PMD’s outdoors only had a significantly lower functional limitation due to a prevalence of poor balance compared to those who used their PMD’s indoor and outdoor (p=0.018).

4.     Patients who used their PMD’s outdoors and those who used their PMD’s outdoors and indoors listed the same 3 environmental barriers as generating the most accessibility problems (mailbox, high threshold/steps, and wall-mounted cupboards/shelves).

5.     Patients reported fewer autonomy restrictions present indoors compared to outdoors.

6.     Patients reported the greatest autonomy restriction for going on trips and vacations when one wants.

Phang et al. 2012




Population: Mean age: 47.7 yr; Gender: males=43, females=11; Level of injury: paraplegia=41, tetraplegia=13; Level of severity: complete=27, incomplete=27, AIS: A=27, B=1, C=15, D=11, E=0.
 Participants completed a questionnaire.
Outcome Measure: 
Leisure Time Physical Activity, Wheelchair Skills Test (WST), Wheelchair-use self-efficacy.
1.    There was a significant positive relationship between wheelchair skills and leisure time physical activity, and wheelchair-use self-efficacy (p<0.05 for both).2.    There was no significance in the relationship between wheelchair-use self-efficacy and leisure time physical activity (p>0.05).
Oyster et al. 2011




Population: Mean age: 39.4 yr; Gender: males=106, females=26; Level of injury: paraplegia=94, tetraplegia=38; Mean time since injury: 11.2 yr.
Participants completed a questionnaire, and were fitted with a custom-designed data-logging device on their wheelchair to monitor their routine daily activities.Outcome Measures: Craig Handicap Assessment Recording Technique (CHART), Wheelchair mobility.
1.   Age was significantly related to wheelchair mobility (p=0.01).2.   Body Mass Index and duration of injury, level of SCI, income, education, and sex were not found to be related to wheelchair mobility.

3.   Participants who used ultralight-weight manual wheelchairs had significantly improved wheelchair mobility (p=0.05) compared to other types.

4.   According to CHART sub-scores, duration of injury, physical independence, and occupation were significantly correlated to mobility (p<0.05).

Cooper 2011




Population: Mean age: 49.1 yr; Gender: males=15, females=1; Level of injury: tetraplegia=9, paraplegia=7; Type of w/c used: manual wheelchair (MWC)=7, power wheelchair (PWC)=9; Mean time since injury: 18.9 yr.Intervention: A survey (PARTS/M) was administered to SCI participants who were participating in the National Veteran’s Wheelchair Games to capture frequency of community participation in the areas of leaving home, transportation, active recreation, leisure activities, and socializing. A data logging device was attached to each participant’s own wheelchair, which recorded their wheelchair activities in their community environment for 2 wk (distance travelled, speed, number of stops and drive time).

Outcome Measures: Participation survey/mobility (PARTS/M) questionnaire; movement activity from data logger.

1.     Subjects travelled an average distance of 3374.07±1677.22 m at an average speed of 0.77±0.17 m/s.2.     Subjects stopped an average of 146.73±91.96 times per day.

3.     Subjects drove an average of 68.65± min/d with a range of 11 to 107 min

4.     Community participation were calculated for only 14 participants due to missing data; scores averaged at 11.98±2.98.

5.     For MWC there was a significant positive correlation between average speed travelled and the community participation areas of transportation (r=.837, p=0.19, p<0.05) and socialization (r=.772, p=0.042, p<0.05); there was also a trend towards a correlation between average speed travelled and total community participation scores (p<0.10).

6.     For PWC there was a trend towards significance between average speed travelled and leisure activities (r1=.636, p-0.006).

7.     No significant differences between wheelchair types were observed in regard to distance travelled and community participation.

Hatchett et al. 2009




Population: Mean age: 35 yr; Gender: males=60, females=7; Level of injury: paraplegia=67; Mean time since injury: 9.9 yr.Intervention: Analysis to determine impact of gender on shoulder muscle strength and community wheelchair (WC) usage in individuals with paraplegia.

Outcome Measures: Maximal isometric peak torque measured using a Biodex System 3 Pro dynomometer, Shoulder flexion, Extension, Abduction, Adduction, Internal rotation, External rotation using a lever which participants pushed or pulled, Community WC usage was measured using the Topeak® bicycle odometer system.


1.     There was a significant difference in normalized shoulder torque between men and women where women were 62%–96% weaker than men (p<0.0001).2.     In both men and women, the shoulder adductors were the strongest muscle group (men=46.8 N·m/kg, women=28.0N·m/kg), followed by the shoulder extensors (men=44.6 N·m/kg, women=27.4 N·m/kg).

3.     Shoulder external rotators were the weakest muscle groups (men=21.7 N·m/kg, women=12.6 N·m/kg).

4.     Significant difference in the average daily distance traveled in the community, with men propelling their WCs 3.1±1.7 km/day and women propelling 1.8±1.2 km/day (p<0.05).

5.     In post hoc analysis, strongest predictor of average daily distance travelled was normalized external rotation torque (R=0.368, R2=0.136, p=0.008).

6.     No significant difference in average velocity of propulsion between men and women (55.9±14.8 m/min and 48.7±9.2 m/min, respectively).

Tolerico 2007




Population: Mean age: 46.8 yr; Gender: males=47, females=5; Injury etiology: SCI=40, muscular dystrophy=1, multiple sclerosis=5, post polio syndrome=1, TBI=1, Guillain-Barre syndrome=1, amputation=3; Range of duration of w/c use: 1-45 yr.Intervention: A datalogger attached to participants’ primary manual wheelchair tracked distance propelled, speed propelled, occupancy during the National Veteran’s Wheelchair Games and an additional week in their home environment following the games for a total of either 13 or 20 days. Demographic information was gathered by survey.

Outcome Measures: Demographic survey including items for age, type of injury/disability, race/ethnicity, gender, type of wheelchair used including make and model, number of years using a wheelchair; for the 2nd and 3rd years questions about employment status, ability to use transportation independently, body weight, primary residential setting, feelings on accessibility and satisfaction with primary wheelchair was added. Movement data from data logger included

1.     98% (n=51) of participants used ultra-lightweight wheelchairs2.     Subjects travelled an average distance of 2457.0±1195.7 m at an average speed of 0.79±0.19 m/s for an average of 8.3±3.3 hr/day.

3.     Subjects accumulated an average of 47.9±21.4 min/day of movement with their primary wheelchair in a home environment over the day.

4.     No significant differences in mobility characteristics, activity levels and level of SCI

5.     There was a significant difference in speed, distance and duration during an average day at the games compared to at home (p<0.001).

6.     Patients’ employment status was significant associated with the average distance travelled (p=0.002), average accumulated min/day (p=0.006), and maximum daily distance travelled between consecutive stops (p=0.01).

7.     Patients reported an average body mass of 85.4±16.0 kg, which did not correlate to mobility characteristics or activity levels.

8.     No significant differences were observed in the patients’ residential setting, satisfaction with primary wheelchair, and perceived influence of community on activities when compared with mobility characteristics and activity levels.

Chaves 2004




Population: Mean age: 41 yr; Gender: men=55, women=15; Level of injury; tetraplegia=29, paraplegia=38; Mean time since injury: 14 yr.Intervention: A survey was administered to SCI participants discharged from two major rehabilitation centres, one in Pittsburgh (Pitts) and one in St, Louis (SL).

Outcome Measures: Participation survey/mobility (PARTS/M) questionnaire using 3 of the 25 major life activities: 1) moving around inside the home which including getting in/out of bed, of the wheelchair and going from room to room2) leaving the home and 3) transportation including accessing and using different forms of transportation.

1.     95% (n=38) of participants with paraplegia used manual wheelchairs; 55%(n=29) of people with tetraplegia used power wheelchairs2.     Participants with paraplegia perceived pain as a limiting factor for transportation use significantly more than people with tetraplegia (tetra=3%, para=21%, p=0.047).

3.     There was a trend towards a lack of equipment being a limiting factor for transportation use for people with tetraplegia more so than for people with paraplegia subjects (tetra=7%, para=3%, p=0.099).

4.     Significant differences were seen between the two test sites with regards to: 1) the type of wheelchair used (p<0.05) where Pitts used more manual wheelchairs (Pitts=87%, SL=67%) and SL used more power wheelchairs (Pitts=13%, SL=33%), 2) A greater percent of SL participants reported wheelchair seating (Pitts=5%, SL=24%, p=0.0285), social attitudes (Pitts=0%, SL=18%, p=0.007), and self-concept (Pitts=0%, SL=15%, p=0.015) as limiting factors for leaving the home; 3) Significantly greater percent of SL patients reported social attitudes as a limiting factor for transportation (Pitts=0%, SL=15%, p=0.017).


Oyster et al. (2011) explored manual wheelchair use by comparing average daily distance travelled, speed, and amount of time spent moving in a wheelchair (distances greater than 15 m) to participant demographics and the Craig Handicap Assessment and Reporting Technique (CHART) subscales of social integration, mobility and occupation. Findings suggest that younger people with SCI travel faster than older counterparts but not significantly further. The average distance travelled was 1877 meters with a standard deviation of 1131, suggesting greater variability in the range of distance travelled. However, the average amount of time spent moving more than 15 meters in the wheelchair was on average 47 minutes per day. The authors did not report on the average amount of time spent in the wheelchair compared to the time moving in the wheelchair. It is also important to note that the movement less than 15 meters were eliminated from this study. Given the apparent limited time moving greater than 15 meters, it is suggested that there is a larger gap in understanding how the wheelchair is being used during the bulk of the day.

Cooper et al. (2011) investigated the correlations between the mobility characteristics of distance travelled, speed, number of stops, and drive time, and frequency of participation in community activities areas of leaving home, transportation, active recreation, socialization and, leisure activities. Findings indicated that on average participants travelled 3,374 meters per day, at an average speed of 0.77 meters per second, for an average driving time of 68.65 minutes a day, stopping an average of 146 times per day. A stop was determined when no mobility activity occurred for more than seven seconds; the authors did not provide reasoning for this decision. Significant correlations were found between average speed travelled and community participation areas of transportation and socialization, for participants who used manual wheelchairs. A trend towards significant correlation was found between community participation area for leisure activities and speed travelled for participants who used power wheelchairs. The authors identified a limitation of their study was that the data logger did not differentiate between home mobility and community mobility and that the community participation areas chosen from the PARTS/M questionnaire were limited to those where participants would be outside of the home. It is also interesting to note that the average driving time was 68.65 minutes per day, which is just over an hour a day; the range was 15.72 to 107.45 minutes per day which when considered over the course of a full day, it raises the question of what activities are people participating in that does not require mobility during the majority of their day.

Tolerico et al. (2007) observed the mobility characteristics of people with SCI who use manual wheelchairs in two different environments; the first was their residential setting and the second the National Veteran’s Wheelchair Games (NVWG). Recruitment occurred at these games for three subsequent years, June 2004 until July 2006. The study results indicated that participants were significantly more active during the games time period than when they were at home; average distance was 6,745.3±1,937.9 meters at 0.96±0.17 meters per second for 12.4±1.7 hours per day compared to an average distance of 2,457±1,195.7 meters at a speed of 0.79±0.19 meters per second for an average of 8.3±3.3 hours per day at home. The authors suggest these findings suggest that people are more active when the environment promotes activity, however, even people who participate in these games, are less active at home by almost half; they also spend less time in the wheelchair.

Karmarkar et al. (2011) observed the mobility patterns of adults over the age of 50 over 5 days during the National Veteran’s Wheelchair Games (NVWG) and compared them to patterns over a two-week period in their home environment. Not surprisingly, the results indicated that regardless of type of wheelchair used, people were more active during the NVWGs than at home. The authors report that the secondary analyses indicate that age negatively affects MWC propulsion velocity but positively affects PWC driving velocity. The authors suggest that their findings support the use of data loggers to examine mobility patterns in the community as well as support that variation in wheelchair use exists depending on the environment therefore further research into this area is needed to fully understand wheelchair use.

Phang et al. (2012) proposed that a contributing factor to the low Leisure Time Physical Activity (LTPA) identified in previous studies may be related to wheelchair skills and therefore self-efficacy. Therefore, the purpose of their study was to determine whether self-efficacy could account for the relationship between wheelchair skills and LTPA in people with SCI. The authors suggest that their findings of a significant relationship between wheelchairs skills and LTPA is consistent with other study results, but the modest size of the relationship suggest other factors in addition to wheelchair skills affect LTPA. The authors also suggest that due to their study design that it is not possible to conclude that better wheelchair skills lead to greater LTPA or vice versa. They do however, suggest that insight into why people with better skills may be more inclined to participate in physical activities can be gained from their results that indicate 50% of the relationship between wheelchairs skills and LTPA were explained by barrier-free self-efficacy. They offer that having better wheelchair skills may bolster self-efficacy to overcome barriers to participation. Interestingly, wheelchair use self-efficacy was found to not be a mediator of the wheelchair skills – LTPA relationship, however, the scores of the wheel-con used for wheelchair use self-efficacy were high, potentially affecting the ability to detect changes. The authors suggest that further research is needed to determine the role of wheelchair skills, in wheelchair use and in overcoming barriers to physical activity participation.

Tsai et al. (2014) reported on correlations between the type of mobility device use, that is externally modified vehicles and powered wheelchairs (power or manual with power assist wheels), and social participation, based on data collected in the National Spinal Cord Injury Database (NSCID). Data examined from 2986 entries suggest that correlations exist between social participation and using a modified vehicle but also between social participation and a wheelchair. The authors suggest their results differ from other studies due to limiting their data to those entries where the person used a wheelchair for more than 40 hours per week and are unable to ambulate more than 150 feet at home.

Chaves et al. (2004) surveyed 70 people with spinal cord injury who use wheelchairs to explore factors that affect the perception of participation in activities in home, in community and during transportation related to the wheelchair, their impairment and the environment. Their primary finding was that the wheelchair was the primary reason cited as a limitation in participation in home, in the community and during transportation. Physical impairment was the second reason most often cited and the wheelchair seating being the third. The top four factors that limited access to participation in the community and transportation use were the wheelchair, the physical environment, lack of assistance and wheelchair seating. The authors surveyed people from two centres in different cities, finding significant differences in the characteristics of the participants and in the perception of participation limitations between the cities/centres.

Petersson et al. (2015) surveyed 48 people who used power wheelchairs to explore differences between those who use their power whelchair only for outdoor mobility compared to those who use it for in and outdoor mobility. The findings suggest that those who use a power wheelchair for in and outdoor mobility use their wheelchair more frequently (significant correlation reported), tend to have more physical limitations, and reported greater autonomy for indoor use. Both groups reported the same environmental barriers for mobility outdoors.

Hatchett et al. (2009) examined shoulder muscle strength and manual wheelchair usage differences based on gender for people with paraplegic level SCI, indicating that the prevalence of SCI for women is increasing and that women have unique attributes that affect these parameters. The strength of all shoulder muscles examined was found to be significantly different between men and women with women’s strength being less than men’s. Hatchett et al. indicated that shoulder torque, after being normalized for body weight, was the strongest predictor of average daily distance travelled in the community, which for women was almost half of the average distance men propelled daily. However, there was no significant difference in average velocity of propulsion between women and men. The authors identify one of the study limitations being the gender disparity in that 60 participants were male and only seven were females; however, they felt it is enough for a preliminary analysis to support further research into gender differences.


There is level 5 evidence (from one observational study: Hatchett et al. 2009) that suggests that shoulder strength is a strong predictor for average daily distance propelled.

There is level 4 evidence (from one pre-post study: Karmarker et al. 2011; and two observational studies: Phang et al. 2012 and Tolerico et al. 2007) to suggest that 1) wheelchair use varies, particularly propulsion distances, 2) propulsion distance are environmentally dependent and 3) distances decrease with increasing age.

There is level 5 evidence (from two observational studies: Cooper et al. 2011 and Oyster et al. 2011) to suggest that of the cumulative time spent in a wheelchair over the course of a day, a small proportion is spent propelling distances, typically just over an hour a day.

There is level 4 evidence (from one case series study: Tsai et al. 2014) to suggest that the type of wheelchair used is not correlated with social participation.

There is level 5 evidence (from two observational studies: Pettersson et al. 2015 and Chaves et al. 2004) that suggests physical barriers and limitations in access, support and assistance negatively effect the use of power and manual wheelchairs in the community.