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Manual Wheelchair Guide

A comprehensive introduction to optimizing manual mobility for client function

One of the greatest barriers to the provision of seating and wheeled mobility is first identifying the need and then documenting and justifying that need for equipment. This guide is meant to be a helpful resource to healthcare professionals

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Purpose of this Guide

One of the greatest barriers to the provision of seating and wheeled mobility is first identifying the need and then documenting and justifying that need for equipment. This guide is meant to be a helpful resource to healthcare professionals to:

  • Identify the need for manual mobility
  • Translate the need for a mobility device to the most appropriate wheelchair model and options
  • Understand how to effectively document and justify the equipment chosen and meet the necessary requirements
  • Understand what the components of an ultra lightweight manual wheelchair are and how to appropriately measure for optimal configuration

Look for these info boxes throughout the guide. They include quick tips or takeaways for that section.

Manual Wheelchair Universal Terms

MWC Terms (1)
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Chapter 1

The Process

The Process

Qualifying for a Manual Wheelchair

Our guide to Wheeled Mobility 101 goes over identifying the need for wheeled mobility so check out that information here. Once you document your patient's need for wheeled mobility you can move on to the next step of qualifying for a manual wheelchair. 

Wheelchair selection is not diagnosis specific and requires evidence of medical necessity. Step one is a physician's visit with notes that state:

Mobility related diagnosis - e.g. hemiplegia due to stroke

  • Symptoms that affect mobility
  • Mobility Related Activities of Daily Living (MRADLs) affected by the mobility limitation
  • Current ambulation limitations. Why they cannot ambulate at a safe, functional level

Then, a referral is made to PT/OT and the fun begins! It becomes our task to evaluate the client and determine what level of wheeled mobility they need to lead safe, functional lives.

The documentation must match from MD to PT/OT! If the MD says they can ambulate or if a diagnosis code does not match, it will be a problem.

Manual Wheelchair Justification

How do I justify my client's need for a wheelchair?

Prior to choosing the type of wheelchair, the PT/OT needs to justify the need for a manual wheelchair.

Ask yourself the following questions, and the answers will begin to guide you towards the right wheelchair:

1. Does your client have a mobility limitation that significantly impairs his/her ability to participate in one or more MRADLs in the home?
  • Does it prevent them from doing MRADLs?
  • Are they unsafe to perform MRADLs?
  • Can they perform MRADLs in a reasonable time frame?

2. Can the mobility limitation be resolved by a cane or walker?

3. Do they have the desire or capability to propel a wheelchair?

  • If they can’t propel, do they have a willing caregiver?

4. Does the client’s home have the space/layout for functional wheelchair use?

  • Measure doorways and ask your ATP for required measurements to get through doorways based on the wheelchair model selected
  • Measure the time it takes to propel the WC to the bathroom from someplace else in the home

Always document how the right equipment allows them to perform routine tasks more independently.

What if your client already uses a wheelchair?

Keep in mind the 5-year lifetime rule. Many insurers will not pay for new equipment unless the current equipment is more than 5 years old or there has been a significant change in medical condition.

If your client uses a wheelchair already, ask the following:

  • How is their posture in their wheelchair?
  • Do they have pain when using their wheelchair?
  • Can they effectively propel their wheelchair?
  • Are they independent in their ADLs?
  • How old is their wheelchair?
  • Was it originally ordered for them, or did they get it from someone else?
  • Consider this: most of us are unaware that a K0004 or lower wheelchair can be a rental. Investigate to find out, is their wheelchair being rented? If so, has it been rented for less than a year? If it has been rented for less than a year, keep in mind that it could be replaced with a different one. 

Just because a person already has a wheelchair, it doesn’t mean it’s the most appropriate one for them!

Chapter 2

DME vs CRT Equipment

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Understanding DME & CRT Equipment

Let's start with the basics. When it comes to seating and wheeled mobility, products are divided into two groups: 

Durable Medical Equipment (DME) and Complex Rehabilitation Technology (CRT).

Check out Wheeled Mobility 101 for more information on DME and CRT equipment.

The Process of Getting a DME Manual Wheelchair

Process Getting DME MWC

What if my client already has a standard DME Manual wheelchair?

You are not limited to the type of wheelchair that your client has used in the past if they could benefit from better equipment.

People, circumstances, legislation, and technology all change over time. If your client already has a wheelchair, it does not automatically mean that it is the most appropriate choice for them now or that it necessarily ever was.

You also have the option to provide ANY type of seating and positioning equipment, even CRT products, for a DME wheelchair if it benefits your client.

It is up to you to advocate for your clients. Perform your evaluations to help justify the proper equipment choices to address your clients' needs now and over time as best you can.

Just because a model of wheelchair was used historically by your client, it doesn’t mean their new equipment should be limited to the same technology.

The Process of Getting a CRT Manual Wheelchair

Process of getting seating equipment

This guide will help you more easily identify the most appropriate mobility device.

Manual Wheelchair Comparison Chart

  Standard Standard Hemi Height Lightweight High-Strength Lightweight Tilt-in-Space Ultra Lightweight
Equipment Category: DME DME DME DME CRT CRT
Medicare Code: K0001 K0002 K0003 K0004 E1161 K0005
Meant for long-term sitting? No No No Only w/ appropriate configuration Yes Yes
Dimensions:
Wheelchair weight without legrests >35 lbs >35 lbs 33-35 lbs 30-34 lbs >45 lbs <30 lbs
Seat width: standard 16", 18", 20" 16", 18", 20" 16", 18", 20" 16", 18", 20", 22" 16", 18", 20" Customizable
Seat depth: standard 16" 16" 16", 18" 16", 18", 20" 16", 18", 20" Customizable
Weight capacity 300 lbs 300 lbs 300 lbs 300 lbs 300 lbs Customizable
Back height 18" 18" 18" 16" to 20" 24" Customizable
Lowest achievable seat-to-floor height 21" 19" 17" 13.5" (most 14.5") 17" Customizable
Adjustability to accommodate for postural abnormality:
Arm rest height No No No Yes Yes Yes
Back height No No No Yes Yes Yes
Seat-to-back angle No No No Yes Yes Yes
Ability to create a fixed tilt No No No Yes Yes Yes
Seat-to-floor height (STFH) No Hemi height only Yes Yes 17"-21" Yes
Legrest options:
Standard, elevating (ELR), & swing away Yes Yes Yes Yes Yes Yes + more
  Heavy duty wheelchairs      
  DME K0006-K0007      
  Same structure and features as K0001-K0003 MWCs, but reinforced for greater weight capacity.      

Note: This chart is for reference purposed only. Wheelchair features vary according to manufacturer and model.

DME, Short-Term Use Wheelchairs

Short-term (and/or part-time) means that the client will only need a wheelchair for a period of time, temporarily during recovery from surgery or mild to moderate injury, and they are not at risk for postural issues or pain. They might use the wheelchair for short periods of time throughout the day and/or for longer distances to reduce fatigue. Below are the types of short-term use wheelchairs:

Standard MWCs: K0001, K0002, K0003
Standard Heavy Duty MWCs: K0006, K0007
Manual Recline WCs: K1225/K1226
High Strength Lightweight MWCs: K0004

 

CRT, Long-Term Use Wheelchairs

Long-term (and/or full-time) means that the client will need a wheelchair indefinitely as their primary means of mobility whether independent or dependent. Below are types of long-term use wheelchairs:

Manual Tilt-in-Space for a dependent wheelchair user
K0005 Ultra lightweight MWC for an independent user

K0005 Ultra Lightweight Manual Wheelchairs

A K0005 wheelchair is the BEST PRACTICE for any full-time wheelchair user!! The K0004 is never "good enough." Below are topics related to the K0005 ultra lightweight manual wheelchair.

CRT ultra lightweight manual wheelchair requirements
Ultra lightweight manual wheelchair rigid vs folding frame
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Manual Wheelchair Guide

Click here to download the Manual Wheelchair Guide as a PDF

Chapter 3

K0005 Configuration

K0005 Ultra Lightweight MWC Configuration

What are the functional characteristics of a highly-customizable wheelchair?

Configuration options Why it matters

Front seat-to-floor height (FSTFH)

Important for safe functional use during propulsion and transfers

Rear seat-to-floor height (RSTFH)

Determines rear wheel accessibility and efficiency of propulsion

Seat slope: difference between the FSTFH & RSTFH

Important for postural stability and optimal wheel access for self-propulsion

Foot support-to-seat length

This affects LE positioning, femoral contact for pressure redistribution, and foot plate clearance

Front frame angle

Legs and feet brought closer to the body make the overall WC footprint smaller, making it easier to get close to things for reaching

Overall frame length

A proper frame length ensures the wheelbase is proportional to the client

Seat width

Affects posture, wheel access for propulsion, and environmental access

Seat depth

Optimizes posture and pressure redistribution

Seat back height

An optimal back support height will balance postural stability and functional reach for ADLs

Seat-to-back angle

This angle provides optimal pelvic and trunk support for stability and daily function

Horizontal & vertical rear wheel axle position

This can be configured for optimal center of gravity and wheel access for the most efficient push stroke

Rear wheels

Affects propulsion, rolling resistance, and weight

Rear wheel camber

Used to increase lateral stability and turning efficiency

Casters

Stability, rolling resistance, and maneuverability

A K0005 is an individually configured, tailor-fit wheelchair. It is not merely small, medium, or large.

Measuring for a K0005 Ultra Lightweight Wheelchair

The features of a manual wheelchair will significantly affect the client and performance of the wheelchair in terms of postural support and wheelchair stability, maneuverability, and ease of propulsion.

This is why the ability to configure a K0005 wheelchair is best practice for a person who uses a wheelchair long-term.

Relating the client's measurements to the wheelchair specifications is key!

K0005 Anatomical & Wheelchair Measurements

Specific Measurements & Configurations

Below are the specific measurements and configurations

Seat-to-floor height (STFH)
Seat slope
Ergo seat
Foot support-to-seat length
Front frame angle
Seat width
Front seat width
Footrest width
Seat sling depth
Frame depth
Seat back height
Seat-to-back angle
Position of the rear wheel axle
Horizontal axle positioning
Vertical axle positioning
Rear wheel options
Rear wheel camber
Caster Options
 

Additional K0005 Ultra Lightweight MWC Options

There are a variety of additional options for K0005 wheelchairs because they are truly the most customizable MWC option. Some are for function, but may not be necessary for every client while others are more client preference.

Configuration options Considerations

Handrim and wheel lock style

Affect use and propulsion (especially for those with limited dexterity), otherwise may be heavily dependent on client preference

Foot plate style

Affects safe foot placement/positioning

Options may include rigid, adjustable, swing-away, flip-up, and flip-back

Arm rest (optional) style, height, attachment

May be needed to promote postural stability

May provide a resting place to reduce fatigue

Height can affect optimal wheel access

Style can affect reaching and transfers

Options may include: adjustable, swing-away, flip-up, and removable. Full and desk length

Side guards (optional) adjustable and/or removable

Consider for postural support and stability

Can provide protection from the wheels during use

Reducing wheel resistance if wheels come in contact with cushion, clothing

Anti-tips

Safety feature for some environments and terrain.

May be fixed, flip-up, removable

Push handles

Will the client be pushed a fair amount of the time? Can added push handles help them maneuver the WC before and after transfer?

The setup of a K0005 MWC demands knowledge of client’s history and potential for function. If not done correctly, the client may not realize that they are at a disadvantage, and it can have long-term effects. Understanding wheelchair types and setup to maximize function will enhance their life and also decrease the risk for complications.

Manual Wheelchair Propulsion

The wheelchair configuration is critical for optimal push efficiency. The goal is long, smooth strokes to decrease the frequency of pushing.

When propulsion forces and repetitions are minimized, the preservation of upper limb function is maximized. This reduces the risk of discomfort, pain, poor function, and injury.Wheelchair Propulsion

The ideal seat height and axle position is when the angle between the upper arm and forearm is between 100° - 120° when the hand is resting on the top center of the pushrim. 

Click on the other propulsion topics below to learn more.

Propulsion Patterns
Propulsion Efficiency
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Chapter 4

Manual Wheelchair Power Assist

Power Assist

What is a wheelchair power assist device?

Power assist is the use of technology to assist with the “push” phase of independent manual wheelchair propulsion. This technology can reduce the push frequency and force required for effective mobility. Power assist can be hub-mounted or rear-mounted. Both styles allow for the rear wheels to be removed, but the weight of the hub-mounted devices are significantly more because there are two motors and batteries, instead of one. A rear-mounted power assist does not require pushing to activate it which frees the hands for function.


What type of person would benefit from power assist?

Although the common misconception is that power assist is used for clients who have pain in their shoulders from overuse, this is a REACTIVE way to use power assist.

What about those wheelchair users who want to be PROACTIVE and use power assist to prevent an overuse injury? Some examples include:

  • The athlete who wants to continue in her sport and continue working out for years to come
  • The office worker who uses power assist to wheel several blocks to his office, to maintain his energy throughout the day
  • The elderly gentleman who has suffered a CVA who is a foot propeller and uses power assist for efficiency

Types of Power Assist

There are different types of power assist devices on the market today. Click on each type to learn more about that option along with the benefits and considerations of each.

Hub-Mounted Power Assist
Rear-Mounted Power Assist

Hub-Mounted Power AssistRear-Mounted Power Assist

Chapter 5

Conclusion

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Conclusion

Why is a K0005 best practice for full time wheelchair users?

A fully customizable wheelchair made of lightest high-strength materials will:

  • Decrease risk of upper extremity pain or injury
  • Contribute to short and long-term functional success
  • Decrease the incidence of secondary complications
  • Last longer than standard wheelchairs
  • All of the above also make them more cost effective
Why is it important to customize frame dimensions?

We maximize client potential through a custom fit.

The evidence-based recommendation from RESNA's position paper "The Application of Ultralight Manual Wheelchairs" states that, "The person cannot conform to the wheelchair, but the wheelchair must conform to the individual." By doing this, we...

  • Optimize roll efficiency of the manual wheelchair
  • Reduce risk of repetitive strain injury over time
  • Aid in postural alignment
  • Reduce risk of pressure injury
  • Improve function

Dimensions & Tips

Frame dimension   Pro Tip

Pro tips are not all inclusive and do not take the place of a skilled wheelchair seating and mobility evaluation

Seat width

Width should only be as wide as necessary, allowing for use of frame to promote postural alignment, improve wheel access, and maximize environmental access

  
Seat depth

Maximize support of the upper leg and pressure distribution without interfering with posterior aspect of lower leg

  
Frame depth

Match frame to client proportionally to the upper leg

Bend of frame should start at popliteal fossa

Matching the frame proportionally to the client results in better weight distribution and unloading of casters, easing propulsion
Ergo seat

Select a size that goes at least 1” past the greater trochanter

For best results, your demo should have an ergo seat
FSTFH

Must consider the cushion being utilized when selecting

Consider transfers, access under tables, desks, and clearance required under foot plate

Seat slope is the difference in front and rear seat heights

Most adults require between 17-19.5” for front seat height

The more bend in the knee, the lower the seat to floor height required for adequate clearance at foot plate
RSTFH

Use rear seat height to maximize wheel access and achieve a more efficient push

Must consider how much seat slope the individual can manage functionally and any range of motion limitations. With client’s upper extremity extended down to the side, middle finger should be at bottom of wheel hub
Overall frame length or front frame angle

Select so that frame is proportional to the length of the client’s side profile while sitting in the desired position

Consider hamstring length, spasticity, overall length of wheelchair

Overall frame length is inherently more accurate than choosing a front angle, so use overall frame length in conjunction with seat depth and custom frame depth
Footrest width

Select a width that allows for adequate space for the client’s feet and tapers to the client’s desired position

Consider 0.5” on each side

Consider transfer style and types of footwear worn
Seat back height

Select a seat back height that allows the prescribed back support to reach desired height for adequate postural support

Have your back support demo on the wheelchair

Seat back angle

Select seat back angle that results in desired support, balance, and optimal spinal curves when seated

  
Center of gravity

Ideally 80% of the client’s body weight on the rear wheel. Achieved this by bringing the rear wheel forward, reducing the amount of weight on the front casters and improving wheel access

With the client’s upper extremity extended down to the side, middle finger should be at center of rear axle, or with client in wheelie, caster should be 2" - 4” off ground

2.5” to 3.5” is typically a good starting point
Camber

Eases initiation of movement and turns, increases lateral stability and, therefore, functional width of wheelchair

Can negatively impact accessibility with adult wheelchairs if >3°
Wheel spacing

May use in combination with camber to achieve a neutral shoulder alignment during propulsion, impacts functional width of the WC

  
Wheel size

Select a wheel size that allows for 100-120° of elbow flexion when the client is at the start of a push stroke

Set seat to floor height first in order to achieve postural stability and environmental access. Then apply the correct wheel size for optimal wheel access

Click here to download the Manual Wheelchair Guide as a PDF.

Click here to view the glossary for the guide.

Click here to view the list of references.