Manual

Wheelchair Guide
A comprehensive introduction to optimizing
manual mobility for client function
Manual Wheelchair Guide

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 a complex rehab
technology (CRT) 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.

This guide was created using process and funding guidelines for the United
States including Medicare coding terminology. Therefore, some terms such
as K0005 and Ultra Lightweight Manual Wheelchair, are considered to be
interchangeable throughout.

This guide is meant to be a comprehensive introduction to manual mobility.

For advanced learning opportunities, visit the education tab at permobil.com

Note This guide is not intended to replace the advice of a medical professional.

4
 Introduction

Table of Contents
Getting started Manual Wheelchair Universal Terms 1
Common Challenges 2
The process Identifying the Need 3
Qualifying for a Manual Wheelchair 4
Manual Wheelchair Justification 5-6
DME vs CRT equipment Understanding DME & CRT Equipment 7
DME 8 - 10
CRT 11 - 14
Manual Wheelchair Comparison Chart 15 - 16
DME, Short-Term Use Wheelchairs 17 - 18
CRT, Full-Time Use Wheelchairs 19 - 20
CRT Ultra Lightweight Manual Wheelchairs 21 - 22
Tips for Justifying a CRT MWC 23 - 24
K0005 Configuration E1161 Manual Tilt-N-Space Configuration 25
K0005 Ultra lightweight MWC Configuration 26
Measuring for a CRT MWC 28
Seat-to-floor height 27 - 30
Seat slope 31 - 32
Ergo seat 33 - 34
Foot support-to-seat length 35
Front frame angle 36
Seat width 37
Front seat width 38
Footrest width 39
Seat sling depth 40
Frame depth 41
Seat back height 42
Seat-to-back angle 43
Position of the rear wheel axle 44
Horizontal axle positioning 45 - 46
Vertical axle positioning 47
MWC propulsion 48
Propulsion patterns 49
Propulsion efficiency 50
Rear wheel options 51
Rear wheel camber 52
Caster options 53 - 54
Additional K0005 Ultra Lightweight MWC options 55
MWC POWER ASSIST Power Assist 56
Hub-Mounted Power Assist 57
Rear-Mounted Power Assist 58
Front-Mounted Power Assist 59
CONCLUSION 61
QUICK GUIDE - MWC FIT 62 - 66
GLOSSARY 67
REFERENCES 68

5
Manual Started
Getting Wheelchair Guide

Manual Wheelchair
Universal Terms

Canes

Back upholstery Handgrip

Arm rest

Side panel

Rear wheel

Seat upholstery Handrim /

pushrim

Front
hanger

Axle

Wheel lock
Foot plate Front fork

Caster wheel

1
 Getting Started

Common Challenges

Lack of experience
identifying the need for
wheeled mobility
Lack of experience
with documentation Lack of formal
requirements education on
wheeled mobility

Challenges to Fear of
Time providing the increased
paperwork
constraints appropriate
wheelchair
Fear of
getting it
wrong
Lack of understanding
of funding sources

Unfamiliarity with the types of

wheelchairs available

Despite wanting what is best for our clients, the above

factors may prevent us from doing it.

2
Manual
The Process
Wheelchair Guide

Identifying the Need

HOW DO I KNOW IF MY PATIENT
NEEDS A WHEELCHAIR?

Consider your patient’s quality of life. Document any

of the indicators below to justify the need.
1. Patient is non-ambulatory
2. Demonstrates decreased safety with ambulation or is at risk for falls within the home.
Ask about history of falls; perform an objective balance assessment, e.g. BERG Balance
Scale (BBS), Dynamic Gait Index (DGI), Timed Up and Go (TUG)
3. Requires assistance for ambulation within the home and wheeled mobility would allow
independence
4. Requires increased time for ambulation within the home. Perform a gait speed test;
think about performing ADLs in a reasonable amount of time
5. Unable to consistently ambulate throughout the day in the home, which affects their
ADLs. Look at a 24-hour period
6. Their current wheelchair is in disrepair or not meeting their needs for mobility or
postural support

Here are scenarios where wheeled mobility could

significantly increase a person’s quality of life:
• They can ambulate but are at high risk of falls
• They have frequent urge incontinence because they are unable to get to the
restroom on time
• Their O2 saturations drop below or heart rate increases above a safe range
with ambulation
• Their day consists of sitting in a recliner and transferring to a bedside
commode as needed
• Nature of their diagnosis, over-fatigue is contraindicated, and a WC is required
in order to avoid exacerbation of symptoms

3
 The Process

Qualifying for a
Manual Wheelchair
NOW THAT I KNOW MY CLIENT WILL BENEFIT
FROM A WHEELCHAIR, WHAT DO I DO?

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 ADLs (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.

4
Manual
The Process
Wheelchair Guide

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.

5
 The Process

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:

1. How is their posture in their wheelchair?

2. Do they have pain when using their wheelchair?
3. Can they effectively propel their wheelchair?
4. Are they independent in their ADLs?
5. How old is their wheelchair?
6. Was it originally ordered for them, or did they get it from someone else?
7. Consider this: 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. More information on page 24.

Just because a person already has a wheelchair, it doesn’t

mean it’s the most appropriate one for them!

6
Manual
DME vs CRT
Wheelchair
Equipment
Guide

Understanding DME &

CRT Equipment
MY CLIENT HAS THE NEED, BUT HOW DO
I GO ABOUT RECOMMENDING THE RIGHT
EQUIPMENT FOR THEM?

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).

Clients will qualify for certain equipment based on the severity

or complexity of their condition. Coverage criteria for CRT MWCs
is based on function. Lesser products must have been tried and
ruled out in documentation.

"CRT products include medically necessary and individually configured manual

and power wheelchairs, seating and positioning systems, and other adaptive
equipment such as standing devices and gait trainers. This specialized equipment
requires evaluation, configuration, fitting, adjustment, or programming to meet
the individual’s medical needs and maximize function and independence.

CRT products must be provided by individuals who are certified, registered

or otherwise credentialed by recognized organizations in the field of CRT and
who are employed by a business specifically accredited by a CMS deemed
accreditation organization to provide CRT."

“National Coalition for Assistive and Rehab Technology.” NCART, 2019, www.ncart.
us/.

7
 DME vs CRT Equipment

DME
DME equipment must meet the following criteria:
• Used for a medical purpose
• Used in the home
• Able to withstand repeated use
• Typically useful for someone who is sick, injured, or disabled

WHO MIGHT BE AN APPROPRIATE USER FOR

DME MOBILITY EQUIPMENT?

The list below can help you identify if your client's

mobility needs might be met by a DME wheelchair:

• Short-term mobility needs (e.g. temporary • Does not have a postural deformity
limitations post-surgery, fracture, or other and is at minimal to no risk for
medical condition) developing one
• Sits in the wheelchair for short periods • Sits in "standard" dimensions without
of time (e.g. for transport pushed by compromise
someone else) • Has normal tone or minimal tonal
• Has limited/no need for positioning abnormalities
support or adjustment beyond that • Has good sitting balance
provided by an appropriate seat cushion or
• Does not have pain with sitting
back support
• Has a non-progressive condition

Medicare requirements for DME equipment:

• Physician order and recent exam documenting need for mobility device
• No PT/OT evaluation or ATP involvement is required
• Specific justification of the product may come from physician or therapist
• On-site home evaluation is not required (but you should always conduct one if you are
involved)

8
Manual
DME vs CRT
Wheelchair
Equipment
Guide

DOES THAT MEAN THAT TYPICALLY CLIENTS

WITHOUT A SERIOUS INJURY OR CONDITION
SHOULD ONLY NEED DME EQUIPMENT?
Definitely not. Go back over the list of qualities that a DME
wheelchair user should have. With your client in mind, if you
answer "no" or "not really" to ANY of those traits, they may
benefit from more advanced equipment.

The populations below (but not limited to) have traditionally been provided
with standard DME equipment. This does not mean that it is actually
appropriate for them.
• Elderly clients • Someone with a low activity level
• Bariatric individuals • Clients dependent in mobility

Always consider best clinical practice when dealing with ANY population and
fight to provide what is most clinically appropriate. Many of these and other
individuals might actually benefit from:
• A lighter weight and optimally configured wheelchair to increase and/or allow their
ability to propel and independently perform ADLs
• Adjustability in their seating system to help maintain posture, prevent deformities, and
decrease pain
• Individualized sizing to increase function, mobility, skin protection, and sitting tolerance
• Ability to tilt-in-space to assist with posture, position, and pressure relief

An appropriate wheelchair that is configured, adjusted, and uniquely fit to

them can increase independence, activity level, and quality of life for more
than just the individual who is already active and independent.

Remember the 5-year rule and consider their prognosis to

ensure you are meeting their needs over time.

9
 DME vs CRT Equipment

The Process of Getting a

DME Manual Wheelchair
Client is a non-ambulator or a Request an order from
non-functional ambulator. the physician.

Based on condition and Contact the DME company to

prognosis, the client will have the wheelchair delivered.
benefit from a wheelchair Remember a cushion should be
for short-term use. used with ANY wheelchair.

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, instead of 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.

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.

10
Manual
DME vs CRT
Wheelchair
Equipment
Guide

CRT
CRT products are significantly different from standard DME. The description
below will help define the difference in products that qualify as CRT:
• Medically necessary, individually-configured manual and power wheelchairs, adaptive
seating systems, alternative positioning systems, and other mobility devices
• Require evaluation, fitting, configuration, adjustment, or programming
• Designed to meet specific and unique medical, physical, and functional needs of
individuals to optimize independence and function.

A primary diagnosis resulting from hemiplegia, hemiparesis, a congenital

disorder, progressive or degenerative neuromuscular disease, or from certain
types of injury or trauma may be a place to start thinking CRT, but do not
limit yourself to those diagnoses.

WHO MIGHT BE AN APPROPRIATE USER

FOR CRT MOBILITY EQUIPMENT?

A seating evaluation will define if there is need for CRT

equipment, but the list below can help you identify the type of
user appropriate for CRT equipment.

• Uses a wheelchair as primary mobility • Needs specific support, configuration,

every day repositioning, and/or adjustments to
• Sits in the wheelchair for long periods maintain posture, protect skin, and
of time maximize function

• Has limitations in sitting balance • Propels on varied surfaces/terrain

indoors and outdoors
• Needs specific dimensions to maintain
posture and optimize function • Has tonal abnormalities that interfere
with positioning/mobility
• At risk for/has current postural
deformities • Has a progressive condition

• Has pain in sitting

11
 DME vs CRT Equipment

Requirements for the provision of CRT equipment:

• MD* has a face-to-face exam and documents the need for a mobility device
• MD* writes order for MWC, PMD, and/or wheelchair seating
• MD* writes referral for wheelchair evaluation or signs PT/OT POC
• OT/PT performs clinical evaluation
• ATP performs technology assessment and equipment trials with PT/OT
• PT/OT writes clinical documentation
• Physician* signs PT/OT documentation
• Supplier/ATP submits paperwork to insurance
• ATP and/or PT/OT deliver, fit, and provide training for equipment
*Could also be a NP, PA, or CNS

Providing CRT equipment:

• Requires more knowledgeable, skilled, and experienced
professionals
• Requires specialized evaluations, measurements, trials,
fittings, training, education, and ongoing modifications
• CRT companies must comply with more rigorous quality
standards under Medicare

Knowing whether your client will be a short-term/part-time

or long-term/full-time wheelchair user, will help you identify
whether they will require DME or CRT equipment.

A CRT wheelchair is going to be best practice for a full-time

wheelchair user every time!

12
Manual
DME vs CRT
Wheelchair
Equipment
Guide

The Process of Getting a

CRT Manual Wheelchair
WHERE DO WE START?

Let's look at the big picture of

how to get CRT equipment:

Nurse/PT/OT or Consumer/family member

identify the need for a wheelchair

Physician/PA/NP:
Outpatient face-to-face appointment OR No need determined.
Inpatient assesses for need Doesn't qualify.

Yes, there is need.

PT/OT eval to assess physical, postural,

and functional issues/limitations related
to patient's ability to perform mobility
related ADLs (MRADLs) safely and within a Doesn't qualify for
reasonable amount of time equipment.

Yes, qualifies for equipment.

13
 DME vs CRT Equipment

PT/OT contacts ATP/Dealer to discuss

what patient qualifies for and options Doesn't qualify for
for equipment equipment.

Yes, qualifies for equipment.

ATP/Dealer meets patient with OT/PT

for evaluation, trial and comparison of
equipment to select the most appropriate
products.

PT/OT completes Letter of Medical

Necessity (LMN)

LMN sent to physician for

signature/approval

LMN submitted and

approved by insurance

Fitting with OT/PT/ATP/Dealer in

outpatient clinic or home

Follow up with patient in 4-6 weeks

for outcomes

14
Manual
DME vs CRT
Wheelchair
Equipment
Guide

Manual Wheelchair
Comparison Chart
Standard
Standard
Hemi Height

Equipment Category: DME DME

Medicare Code: K0001 K0002

Meant for long-term sitting? No No

Dimensions:

Wheelchair weight without legrests >35 lbs >35 lbs

Seat width: standard 16", 18", 20" 16", 18", 20"

Seat depth: standard 16" 16"

Weight capacity 300 lbs 300 lbs

Back height 18" 18"

Lowest achievable seat-to-floor height 21" 19"

Adjustability to accommodate for postural abnormality:

Arm rest height No No

Back height No No

Seat-to-back angle No No

Ability to create a fixed tilt No No

Seat-to-floor height (STFH) No Hemi height only

Legrest options:

Standard, elevating (ELR), & swing-away Yes Yes

Heavy duty wheelchairs
DME K0006-K0007
Same structure and features as
K0001-K0003 MWCs, but reinforced
for greater weight capacity.

15
 DME vs CRT Equipment

High-Strength
Lightweight Tilt-in-Space Ultra Lightweight
Lightweight

DME DME CRT CRT

K0003 K0004 E1161 K0005

Only w/ appropriate
No Yes Yes
configuration

33 - 35 lbs 30 - 34 lbs >45 lbs <30 lbs

16", 18", 20" 16", 18", 20", 22" 15" - 19" Customizable

16", 18" 16", 18", 20" 15" - 19" Customizable

300 lbs 300 lbs 300 lbs Customizable

18" 16" to 20" 25" Customizable

17" 13.5" (most 14.5") 12" Customizable

No Yes Yes Yes

No Yes Yes Yes

No Yes Yes Yes

No Yes Yes Yes

Yes Yes 12" - 21" Yes

Yes Yes Yes Yes + more

This chart is for reference purposes only.

Note
Wheelchair features vary according to manufacturer and model.

16
Manual
DME vs CRT
Wheelchair
Equipment
Guide

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.

Standard MWCs: (K0001, K0002, K0003)

Standard Heavy Duty MWCs: (K0006, K0007)
These wheelchairs are most
appropriate for use on firm, level
surfaces and are not appropriate for
full-time/long-term use.

Considerations Why it matters

Cannot be optimally configured to an individual which
Minimal adjustability if any can result in decreased comfort, inefficient propulsion,
and poor postural support
Solid tires are not designed for uneven terrain, carpet,
Front casters and tires are
or sloped surfaces and can increase difficulty of
usually solid
propulsion
Weight is distributed to the front caster, making the
Rear wheel position is fixed wheelchair harder to push. This wheel position results in
and rearward an inefficient push stroke, leading to fatigue and risk of
shoulder injury over time
This makes ANY self-propulsion inefficient and puts the
Heavy
user at risk for fatigue and injury
Inappropriate arm rest height can interfere with
Arm rest height is not propulsion and can affect the overall seated posture.
adjustable This can also increase the risk of postural deformity
over time
Minimal seat-to-floor height
STFH affects foot propulsion
(STFH) adjustment if any

17
 DME vs CRT Equipment

Manual Recline WCs: (E1225/E1226):

These wheelchairs are similar in features
to standard WCs, but provide the option of
changing the seat-to-back angle. The back
support has an extension that supports the
head posteriorly when reclined.

Considerations Why it matters

Heavier due to hardware, back height, Makes it more difficult to self-propel and
elevating legrests, anti-tip bars transport
Same consideration as Standard MWCs (previous page)

E1225 = semi-reclining (15° & 80°), E1226 = fully-reclining (80° or greater)

High Strength Lightweight MWCs: (K0004)

A K0004 is similar to a standard wheelchair, but
is designed to be somewhat lighter and more
adjustable. They are not intended for full-time/
long-term use, but for part-time or intermittent
use on firm, level surfaces. They may be partially
disassembled by caregivers for transport.

Considerations Why it matters

This can improve self-propulsion efficiency
Some have partial rear seat-to-floor height
and/or create a "fixed dump" or seat slope
adjustability
for positioning
Have lower achievable STFH of 14.5" This can allow for better foot propulsion for
compared to Standard MWCs average lower leg length individuals
This allows for changing the seat-to-back
Some have back cane adjustability
angle (STBA)
This allows for improved rear wheel access
Some have arm rest height adjustability
and postural support

ALWAYS verify K0004 features before ordering. Not ALL K0004 MWC models have
adjustability
18
DME vs CRT
Manual Equipment
Wheelchair Guide

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.

Manual Tilt-in-Space when positioning is the priority

When is a Tilt-in-Space wheelchair appropriate?

• Client is dependent in mobility
• Client is unable to perform independent pressure relief
• Client requires tilt pressure reliefs during the day and is able to perform tilt-in-space
pressure relief via self-activated lever
• Client requires postural support, head and trunk control, and accommodation of
postural asymmetries
• The goal is to increase sitting tolerance/endurance through changing positions or
pressure management
• Client needs improved line of sight due to forward head posture
• Client will benefit from trunk support and open thoracic posture for increased
respiratory function
• Client requires safe positioning for feeding/gravity-assisted swallowing
• Client is requires gravity assisted positioning and can utilize UEs and/or LEs for
self-propulsion

A manual tilt-in-space wheelchair requires a PT/OT evaluation,

justification that other manual wheelchairs are not appropriate, and an
ATP involved in the process.

19
 DME vs CRT Equipment

Ultra-lightweight MWC when independent propulsion is

the priority

This is THE manual wheelchair for a full-time wheelchair user with goals
to be active at home and in the community. These wheelchairs can be
individually configured to meet the needs of the wheelchair user and
optimize function and propulsion. They are designed to be used on indoor
and outdoor surfaces in the community and can be folding or rigid.

A K0005 wheelchair is the BEST PRACTICE for any full-time

wheelchair propeller!! The K0004 is never "good enough."

20
Manual
DME vs CRT
Wheelchair
Equipment
Guide

CRT Ultra Lightweight

Manual Wheelchairs
Requirements:
• Client is a full-time/long-term
wheelchair user
Seat width
• Client requires customization such
as axle configuration, wheel camber
angle, front and/or rear seat-to-floor
height (seat slope), or WC frame size
that can’t be accommodated by a
K0001-K0004
• This requires an evaluation by a PT/
OT, a letter of medical necessity,
and the involvement of an ATP in the
equipment selection process Wheel camber

Seat slope

Axle
adjustment

Front frame angle

21
 DME vs CRT Equipment

Rigid vs folding frame

Cross bars
connect frame
One-piece
frame
Removable
Integrated
leg rests
leg rests

Rigid Folding
• One-piece frame is comprised of bent • Two-piece frame connected with cross bars
and/or welded tubes for folding
• Leg rest hangers are integrated • Removable/swing-away leg rests

Why use a rigid frame? Why use a folding frame?

Generally lighter weight due to less parts. User choice! If someone has been using
This is significant for push efficiency and a folding WC for a long time or just likes
loading into vehicles. Fewer parts can folding frame wheelchairs, then that is
increase durability. reason enough.
Standing, or partial standing, transfers are
More rigid equals more efficient. Folding easier with swing-away leg rests. There
frames will flex more which takes energy are options on rigid frame wheelchairs, but
away from the push. generally a folding WC is easier for these
clients.
People who propel the wheelchair with
Rigid frame wheelchairs fit in small areas
their feet. There are options for rigid frame
as well! Consider a fold-down back &
wheelchairs, but they tend to require custom
quick release wheels.
builds.
If there is need for elevating leg rests
Transport efficiency for bariatric clients

22
Manual
DME Wheelchair
vs CRT Guide
Equipment

Tips for Justifying an Ultra-light-

weight or Manual Tilt-in-Space chair:
HOW CAN I MAKE SURE THAT MY CLIENT GETS
THE MWC THEY NEED?

Qualification for a CRT MWC is functionally based, not

diagnosis based. Rule out a lesser DME wheelchairs by
documenting why the “least costly” alternative is not effective.
Include a description of the client’s routine activities and
whether they are fully independent in the use of the wheelchair.
1. Use objective tests and measures such as a Wheelchair Propulsion Test
Compare an optimally configured ultra lightweight wheelchair vs. lower-end wheelchair;
time propulsion over a fixed distance; count push strokes; differentiate quality of
propulsion; document pain; pulse oximetery
2. Compare safety, efficiency, and ability to independently complete all mobility related
activities of daily living (MRADLs) all day, every day, with a lesser MWC
3. Consider the need to configure an ultra lightweight wheelchair for better posture and
mobility
4. Document the unique features of a ultra-lightweight manual wheelchair and why
they are needed:
• Adjustable front and rear seat-to- • Axle adjustability
floor heights • Seat slope
• Individualized seat and frame • Rear wheel camber
width and depth
• Seat back angle
OR,
5. Document the unique features of a Manual Tilt-in-Space chair and why they are needed.
The ability to tilt the wheelchair seat posteriorly to:
- maintain position in the chair due to spasticity, decreased trunk control, or
endurance
- to provide gravity assisted positioning required for optimal posture due to
postural asymmetries
- to assist with pressure management during the day
- to change positions for activities of daily living

Examples why the features may be needed:

Adjustable axle plate is required for center of gravity adjustment to allow for efficient
propulsion and decreased shoulder pain from 6/10 to 0/10.

23
 DME vs CRT Equipment

Adjustable axle needed to allow for efficient propulsion compared to a lesser WC:
Person took 35 push strokes & 5 min to propel 40' to bathroom, compared to ultra
lightweight WC, where it took 15 push strokes & 2 minutes.
Additional seat size options are required as my client of 6’ and 170 lbs does not fit the
standard configurations of lower-end manual wheelchairs.
A manual tilt-in-space chair is required to provide regular weight shifts in the chair
throughout the day; my client is unable to perform an effective pressure relief and is
at risk for skin breakdown.

HOW CAN I GO ABOUT GETTING THE APPROPRIATE

WC WHEN CLIENTS ARE DISCHARGED SO EARLY?

This is a common challenge with inpatient rehab stays getting

shorter and shorter, but it is still possible.

The first thing to consider when doing your initial evaluation is whether
or not your client may need a wheelchair full-time when going home. If
the answer is "yes," treat your evaluation as if they are going to need a CRT
wheelchair, even if they initially go home in a lower-end manual wheelchair
for a short period of time. What do I do?

1. Plan of Care - Include in the Plan of Care that the client is to follow up with the next clinician
in the continuum and the supplier after discharge to obtain the ultra lightweight MWC that is
recommended.
2. Talk to your client - Empower them by explaining that they are going home in a rental
wheelchair that will turn into a purchase in 12 months. Encourage them to talk to the next
therapist in the continuum about getting a better ultra lightweight wheelchair.
3. Rule out a K0001 - K0004 WC - Document using the methods outlined on page 23.
Documentation must show why the “least costly” alternative is not effective.

The rental wheelchair or demo WC from the dealer/ATP will buy time for
completing the evaluation and procurement process so your client can get the
wheelchair they deserve.

Remember to consider the 5-Year Rule. A client in a lower-end wheelchair that

isn’t going to meet their long-term needs is not the most beneficial option to
them. With the useful lifetime rules, a client must remain in the same WC for 5
years (longer with some funding sources), unless they have a change in medi-
cal condition that warrants another new wheelchair.

Mobility needs upon discharge need to be considered FROM DAY

ONE of the rehab stay!!!

24
Manual Wheelchair Guide

E1161 Manual Tilt-N-Space

Configuration
WHAT ARE THE FUNCTIONAL CHARACTERISTICS
OF A HIGHLY-CUSTOMIZABLE WC?

Configuration options Why it matters

Front seat-to-floor height
Important for safe functional use and transfers
(FSTFH) (Pages 27-28)
Adjustable Rear seat-to-floor
Assists with pressure relief and wheel access
height (RSTFH) (Pages 27-28)
Seat slope: difference between
Important for postural stability and optimal wheel
the FSTFH & RSTFH (Pages
access for self-propulsion
29-30)
Foot support-to-seat length Affects LE positioning w/ femoral contact for pressure
(Page 33) redistribution or propulsion
Affects posture, wheel access for propulsion, and
Seat width (Page 35)
environmental access
Seat depth (Page 38) Optimizes posture and pressure redistribution
Horizontal rear wheel axle
Improved push stroke for client
position (Pages 42-45)

Weight capacity Accommodating pediatric to bariatric enduser

25
K0005 Configuration

K0005 Ultra lightweight

MWC Configuration
WHAT ARE THE FUNCTIONAL CHARACTERISTICS
OF A HIGHLY-CUSTOMIZABLE WC?

Configuration options Why it matters

Front seat-to-floor height Important for safe functional use during propulsion and
(FSTFH) (Pages 27-28) transfers
Rear seat-to-floor height Determines rear wheel accessibility and efficiency of
(RSTFH) (Pages 27-28) propulsion
Seat slope: difference between
Important for postural stability and optimal wheel
the FSTFH & RSTFH (Pages
access for self-propulsion
29-30)
Foot support-to-seat length This affects LE positioning, femoral contact for
(Page 33) pressure redistribution, and foot plate clearance
Legs and feet brought closer to the body make the
Front frame angle
overall WC footprint smaller, making it easier to get
(Page 34)
close to things for reaching
Overall frame length A proper frame length ensures the wheelbase is
(Page 60) proportional to the client
Affects posture, wheel access for propulsion, and
Seat width (Page 35)
environmental access
Seat depth (Page 38) Optimizes posture and pressure redistribution
An optimal back support height will balance postural
Seat back height (Page 40)
stability and functional reach for ADLs
This angle provides optimal pelvic and trunk support for
Seat-to-back angle (Page 41)
stability and daily function
Horizontal & vertical rear wheel This can be configured for optimal center of gravity and
axle position (Pages 42-45) wheel access for the most efficient push stroke

Rear wheels (Page 49) Affects propulsion, rolling resistance, and weight

Rear wheel camber (Page 50) Used to increase lateral stability and turning efficiency

Casters (Pages 51-52) Stability, rolling resistance, and maneuverability

A K0005 is an individually configured, tailor-fit wheelchair. It is not merely

small, medium, or large.

26
ManualConfiguration
K0005 Wheelchair Guide

27
Measuring for a CRT manual
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 CRT manual wheelchair is best
practice for a person who uses a wheelchair long-term.

Relating the client's measurements to the wheelchair

specifications is key!

Anatomical measurements Wheelchair measurements

from mat evaluation to be performed with the person in a WC seated in
their desired position of propulsion

Upper leg length

Custom frame depth

Seat sling depth
Upper leg length

Seat width Seat width

28
K0005 Configuration

Seat-to-floor height (STFH)

The front and rear seat-to-floor height is usually not the same in an
optimally configured K0005 MWC. (visual on next page)

Front STFH measurement

WC measurement is from where the leading edge of the seat upholstery
meets the frame of the wheelchair to the floor.

Anatomical measurement is meant to match the dimensions of the lower leg

along with the foot plate to ensure lower extremity support and accessibility.
• An appropriate height will provide proper support of the thighs and lower legs to
optimize stability and pressure redistribution

Rear STFH measurement

WC measurement is from the wheelchair frame seat tube to floor, right in front
of the back post. You must have the client in a WC to determine their RSTFH
• This height is meant to ensure appropriate access to wheel handrims for optimal
propulsion. Optimal RSTFH is when the finger tips of the client touch the axle of the wheel.
See "Vertical axle positioning" (page 45) for more
• A lower rear STFH relative to the front STFH can provide increased postural stability for
those with impaired trunk control

Foot plate height measurement

WC measurement is the distance from the top of the footplate to the seat
upholstery. It should be equal to the lower leg length minus the height of the
cushion. See page 33 for more.

Always consider the wheelchair seat cushion thickness and clearance of

tables and desks when measuring STFH!
For determining both the front and rear STFH, keep in mind that some
seat cushions may have a different thickness in the front and the rear of
the cushion. The difference will affect seat slope if not accounted for.

29
 K0005 Configuration

FSTFH
RSTFH

Foot plate
height

USE A DEMO! All WC measurements should be completed

with the client in a demo wheelchair! The demo does not
have to be perfect for your client, but it will give the best
starting point for fitting them.

30
K0005 Configuration

Seat slope

The seat slope is the difference between the front and rear STFH
and is important for postural stability and optimal wheel access for
propulsion.

• The greater the seat slope from front to back, the more passive stability is provided for
those with decreased trunk control
• Consider available hip and knee range of motion when determining seat slope
• Insufficient seat slope may make sitting up difficult while too much seat slope may make
transfers more difficult

Seat slope
Sample - 2"

Front STFH
Sample - 18" Rear STFH
Sample - 16"

Most adults need about 2" seat slope if they propel with
their UEs. Foot propellers need 0 - 1" of seat slope.

31
 K0005 Configuration

Utilizing an ergonomic (ergo) seat on an ultra

lightweight MWC
Sometimes a conventional seat slope won’t work for these reasons:
• There is an insufficient range of motion (ROM) at the hip and/or knee required for the
slope
• The individual requires 3" or more seat slope for stability and rear wheel access With
3" or more of seat slope an acute hip-to-back angle is created so even a WC user with
normal ROM cannot access the rear portion of the seat
• Individual may feel unstable
• Individual complains of pain
• Individual complains of sliding forward

Example of limited ROM at the hip: Individual slides into an abnormal posture by shifting
their legs and pelvis forward to open the angle back up for comfort. Then, they slouch
forward to maintain their center of gravity/stability.

32
K0005 Configuration

Ergo seat for ultra lightweight

manual wheelchairs

An ergonomic seat is intended to match an individual’s shape

while providing a lower RSTFH relative to the front. The RSTFH is
maintained for a length of the frame before the seat tubing ascends
up to the FSTFH specified.

• This promotes an upright posture by maintaining a more open STBA compared to a

conventional seat slope
• It allows for better stability, positioning, and pressure distribution by creating a stable,
neutral place to seat the pelvis and load the femurs
• Allows improved rear wheel access for more efficient propulsion
• It optimizes total surface contact area, increasing pressure redistribution for the bony
prominences and encouraging pelvic stability
• The shape allows the thighs to be more level, making it easier to carry items during daily
tasks

Ergo seat measurement

WC measurement is from the back post of
the WC to the point in the tubing where you
want it to start to bend upwardly.

Anatomical measurement is from behind

the hip to the greater trochanter, plus 1 - 2".

Instability from an increased seat slope can be offset by

using an ergo seat when clinically appropriate for the user.

33
 K0005 Configuration

The idea is to contain the ITs within the flat ergo well. Since the frame is providing
the positioning, the goals of the cushion need to be consistent with the goals of the
wheelchair. The cushion needs to follow the contour of the frame and provide a
flexible pressure relieving interface between the frame and the wheelchair user.

Ischial landing spot

3" ¾"

Conventional Ergonomic seat

seat slope

34
K0005 Configuration

Foot support-to-seat length

The foot support-to-seat length is also known as leg rest length. It is

important to provide lower extremity support, ensuring optimal femoral
contact at the seat surface and clearance of obstacles at the footplates.
It is important to use a demo wheelchair with the person in the
desired position of propulsion, to get the most accurate measurement.

Foot support-to-seat - too short

• This can raise the knees which reduces
clearance for under tables and increase
slope of the upper legs which can make it
harder to carry items
• Can reduce femoral contact and increase
peak pressure at the ITs

Foot support-to-seat - too long

• Lower legs are unsupported and pressure
increases distal femur. The client may slide
forward to reach the foot support, and by
doing so, shift into a posterior pelvic tilt
• This can increase risk of a postural
abnormality and peak pressures at the
seat and back support surfaces

35
 K0005 Configuration

Front frame angle

Front frame angle is critical to provide appropriate support to the

lower extremities.

This should be set by asking the client

where they want their feet (further in or
out) and have the client place their feet
where they want them. The front frame
angle selected should be the one where
the ball of the client's foot can rest on the
foot rest tube. Measuring for the overall
frame length is a more accurate way of
determining the appropriate front frame
angle for a client. See page 60 for more.

Example visual: A tall individual may need to tuck their legs in tight under the WC due to their
longer lower leg length. This allows them to still clear the edges of tables, desks, counters and
keep their overall wheelchair footprint smaller. They must have an available ROM at the knee
for this.
36
K0005 Configuration

Seat width

Measuring the appropriate seat width is critical for postural stability

and propulsion efficiency.

Seat width measurement

WC measurement is outside to outside of seat tubes at the back post. This
should match the client's anatomical measurement.

Anatomical measurement is the widest point of the body at the hips including
all residual tissue.
• The seat width affects the overall width
of the wheelchair along with wheels and
handrims

Seat width

Seat width - too narrow

• This can lead to unwanted pressure and postural abnormalities due to compensation

Seat width - too wide

• This can make it difficult to access the handrims and result in inefficient propulsion
which can cause upper extremity injuries over time
• Negatively affects environmental accessibility and positioning/posture in the WC

37
 K0005 Configuration

Front seat width

This measurement allows you to taper the front of the seat to match
the client's posture. Front seat width can also be referred to as the seat
taper.

Not all client's need to have a tapered seat. However, client's whose LEs are
much narrower than their hips may benefit from front seat taper to:
• Provide better LE positioning with better overall WC fit
• Allow the ability to get closer to things for transfers and reaching
• Provide a smaller overall footprint for accessibility
• "See me, not the wheelchair"

Front seat width measurement

WC measurement is inside of front frame tube to inside of opposite front
frame tube.

Anatomical measurement is the width across the client's legs across the distal
end of the femurs, proximal to the knees. This width should match the front
seat width measurement.

Seat taper starts

approximately 9" from
the back posts

Front seat width

38
K0005 Configuration

Footrest width

This measurement allows you to match the footplate with a LE

positioning that is comfortable for the client. Someone who has large
legs or LE edema may not need any front seat taper. Someone whose
lower legs are smaller than their hip width may need some leg rest taper.

Footrest width measurement

Select a width that allows for adequate space for the client’s feet and tapers to
the client’s desired position. Measure across both the client's feet with shoes.

Footrest Footrest
width width
(Standard) (V)

Standard - Inside of front frame tube V - Inside of front frame tube to inside
to inside of opposite front frame tube of opposite front frame tube 2 ½”
above footrest

Footrest width - too tight

• The tubes press on the client's legs or feet
• The footplate may not be wide enough to allow the feet to pivot for transfers if the client
leaves their feet on the footplate for transfers

Footrest width - too loose

• The client does not have adequate foot/LE positioning coming from the WC. Legs and
feet may lose position, especially with spasticity or going over bumps
• This can decrease environmental access by increasing the WC footprint

39
 K0005 Configuration

Seat sling depth

The goal of seat sling depth is to maximize support and pressure

distribution without interfering with LE positioning. An appropriate
depth will provide optimal stability in the wheelchair.

Seat depth measurement

WC measurement is from the back posts to the leading edge of the seat
upholstery.

Seat depth

Anatomical measurement is from behind the user's hip including residual tissue
to their popliteal fossa AND should account for where they want to position
their legs, more or less tucked.

Seat depth - too short

• Decreases femoral contact for pressure distribution which can lead to pressure injury

Seat depth - too long

• This may result in sliding forward to decrease pressure behind the knees, resulting in poor
posture and decreased propulsion efficiency

40
 K0005 Configuration

Frame depth

The frame depth is measured from the front of the back cane to
the front frame bend. The center point of the trailing front caster is
usually lined up with the front frame bend, resulting in a balanced
wheelchair for optimal stability and propulsion.

Frame depth

Frame depth on a rigid wheelchair should be set so that the bend in the
frame lines up with the bend in the user's leg. This results in a balanced
wheelchair because the front casters will move forward proportionally to
the end user's body when frame length is added to fit their shape.

If you notice anterior instability, caster loading, or impaired

maneuverability, check the frame depth!

41
 K0005 Configuration

Seat back height

Proper back height in a K0005 is important for providing appropriate

postural support and upper extremity function for propulsion.

Seat back height measurement Seat back height

The WC measurement is from the top of
the back post to the top of the seat tube
at the back post.

Select a seat back height that allows the

prescribed back support to reach desired
height to for adequate postural support.

An optimal back support height is determined

by the lowest point of the trunk needing
support for stability and function.

Back support - too high Back support - too low

• May limit scapular movement during • May result in a feeling of instability
propulsion which impacts upper • Individual may slide into a posterior pelvic
extremity range of motion tilt seeking stability. This can increase peak
pressures and promote abnormal posture

When measuring for a manual tilt-in-space chair the back height should
support the full length of the trunk, especially when in the tilted position.
Measure from the seat to the top of the shoulder and consider the height
of the cushion being recommended.

42
K0005 Configuration

Seat-to-back angle

The seat-to-back angle (STBA) is critical for postural support and

assuring the best position for efficient propulsion. Most adults need
the STBA open a few degrees to allow room for their normal spinal
curves. This angle can be further adjusted to the client's needs using
adjustment on the back support mounting hardware and on the
wheelchair itself if available.

STBA measurement 90°

On the WC, seat-to-back angle <90° STBA >90° STBA
is measured from the front of Closed STBA Open STBA

the back post to the floor.

• Greater than 90° may improve postural stability for individuals with impaired trunk
control and/or limitations in hip range of motion. 92° - 93° may provide the lumbar area
support for promoting normal spinal curves.

Manual tilt-in-space wheelchair users often require a more open STBA

to assist with balance and/or accommodate for the seating system
recommended. In addition, some manual tilt-in-space chairs are also
available with manual recline to further assist with positioning, balance,
and activities of daily living in the wheelchair.

43
 K0005 Configuration

Position of the rear wheel axle

The horizontal and vertical positions of the rear wheel axle, have
a significant impact on all of the functional characteristics of the
wheelchair such as:

• stability • turning radius

• weight distribution • wheel access

Keep in mind that a forward axle position reduces the forces needed to propel
and the rear axle should be set for the center of mass of the client.

Weight distribution and configuration have a greater impact

on ease of wheelchair propulsion than overall mass of the
chair. This applies to upper extremity, lower extremity and
hemi-propulsion styles, as well as to a caregiver who is
pushing the wheelchair.
Every full-time, long-term wheelchair user should have the
rear wheel positioned uniquely for them to prevent injury and
ensure full access to their environment.

44
K0005 Configuration

Horizontal axle positioning

The horizontal axle position

will determine the wheelchair
center of gravity (COG).

When the axle is under the center

of mass of the client, the majority of
their weight is on the large rear wheel.
Ideally, this is about 80% of their body
weight. If weight is not on the rear
wheels, it will load the front casters,
requiring more force to roll the WC.

Horizontal axle measurement

WC measurement is the horizontal
distance from the front of the back
post to the center of the rear axle of
the wheelchair.

Best practice is to position the rear wheel as far forward as possible without
unsafe rear instability or caster interference.
Some manual tilt-in-space wheelchairs offer the ability to adjust the center
of gravity horizontally to assist with weight distribution for propulsion and
stability in the chair. Other manual tilt-in-space chairs offer the option of a
reverse configuration (large drive wheel in the front) to facilitate access to the
drive wheel for propulsion.

45
 K0005 Configuration

Forward axle Rearward axle

Rearward center of mass Forward center of mass

Benefits Benefits
Allows for more efficient upper extremity The WC will be more stable in the rear*
position for propulsion
Increases frontward stability of the Considerations
WC. WC is less likely to tip forwards Less efficient upper extremity position to
when rolling down, reaching forward, or reach rims, could lead to injury over time
scooting forward for transfers Increases the forces necessary to turn the
Decreases turning radius and overall wheelchair
footprint of the wheelchair, making it easier Increased rolling resistance makes it harder
to navigate small spaces to propel
Increases ease of performing a wheelie to Increases difficulty of performing a wheelie
maneuver obstacles to maneuver obstacles
Increases the turning radius and length of
Considerations the wheelchair footprint, making it difficult
If too far forward, it increases the risk of to navigate small spaces
wheelchair tipping backwards *Increases risk of WC tipping forward

46
K0005 Configuration

Vertical axle positioning

Proper vertical axle position allows for optimal upper extremity position
for propulsion. Vertical axle position determines RSTFH measurement
and therefore affects seat slope.

Lower axle (on axle post) Higher axle (on axle post)
Higher RSTFH, less seat slope Lower RSTFH, more seat slope

Vertical axle measurement

The vertical position of the axle is
determined by how high or low the
RSTFH of the wheelchair needs to be.
Remember to account for cushion
thickness here.

For client's with hand function,

finger tips should touch the center
of the rear axle when sitting upright
with arms to the side. For those with
tetraplegia, use the thenar eminence
instead as your reference point.

Effective / efficient propulsion is affected if the vertical

position is too high or low, and it may place the upper
extremities in a position that could cause injury over time.

47
 K0005 Configuration

MWC 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.

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.

— 100° to — 120° angle

For lower extremity or hemi-propulsion, optimal position

also includes a FSTF that is up to 2" lower than the lower leg
length to allow good foot contact with the ground, as well as
0-1" seat slope and a 95 degree open back angle.

48
K0005 Configuration

Upper extremity propulsion patterns

There are four upper extremity stroke techniques consisting of a

push phase and a recovery phase. The pattern of recovery (release to
contact) is the largest difference between techniques.

Contact
Release

Semicircular Single loop over

Arc Double loop over

The semicircular pattern is encouraged because:

• It promotes better biomechanics
• It is associated with lower stroke frequency
• It promotes more time in push phase than recovery phase
• The hand follows an elliptical pattern with no quick changes in direction and no extra
hand movements

Single loop over is the most common pattern for individuals with paraplegia.

49
 K0005 Configuration

Propulsion efficiency

A forward axle position allows for longer, smooth push strokes which
will also decrease frequency of pushes.

Forward axle -
Distance between
contact & release

A rearward axle position reduces the user's ability to get a long stroke since
they are starting the push phase near the front of the rear wheel.

Rearward axle -
Distance between
contact & release

A forward axle position distributes the user's weight over the rear
wheel, making propulsion easier. A rearward axle position puts
more weight on the front casters, adding more rolling resistance
making propulsion more difficult.

50
K0005 Configuration

Rear wheel options

Wheel type and size are important to minimize rolling resistance,

decrease weight, and increase reliability of the system.

Rear wheel size

Diameter of the wheel is determined by the optimal RSTFH for a client.
For example, a taller person may need a larger diameter wheel.

Rear wheels - too large

• The seat-to-floor height and access to the hand rims may be compromised
• A larger diameter wheel may interfere with transfers since they create a little bit bigger
hurdle to transfer over
• A larger wheel will increase the length of the wheelchair footprint. This could negatively
affect client reach, ADLs, and wheelchair maneuverability

Pneumatic vs Non-pneumatic tires

Pneumatic tires: (filled with compressed air)

• Weigh less with better shock absorption

• Must be inflated properly for optimal propulsion, under inflated tires are less efficient
and harder to propel. Under inflation is a common occurrence
• High pressure pneumatic tires have lower rolling resistance (RR)

Non-pneumatic tire:
• May be solid or pneumatic with flat-free inserts
• Airless insert and solid tires have highest RR and low efficiency
• Often used when a flat-tire could be a safety risk because the ability to properly
maintain pneumatic tires is in question
• Solid tires may have reduced maintenance

Evidence shows that the perceived weight equivalent of airless insert tires is the same
as adding 96 pounds of weight that the user must carry.
Consider thoroughly ruling out high pressure pneumatic tires before recommending flat
free inserts. https://bit.ly/3XwXAMe
Choose a tire that is lightweight to decrease the initial force required to turn the
wheels. Low tread and the least amount of surface contact to the ground decreases
rolling resistance.

51
 K0005 Configuration

Rear wheel camber

Camber is the inward tilt of the rear wheel. The camber angle affects
lateral stability and the efficiency of propulsion as well as rear wheel
access. When performing tasks that require leaning outside the
footprint of the wheelchair, increased camber will increase stability
and promote maintaining an upright position in the wheelchair.

Sample 0° Sample 4° Sample 7°

Most adult wheelchairs used for daily use have 0° - 3° of camber while
pediatric sizes may have more to improve wheel access. Wheel camber
decreases proximal distance to the user at the top for wheel while increasing
distance between wheels at ground level.

Sports WCs have greater than 3° degrees camber for stability. The extra wide
camber also increases the ease of propulsion (longer lever arm).

Rear wheel spacing is the distance between the top of the wheel and the
back post. The goal is the narrowest possible configuration to allow the most
accessibility.

• Different amounts of rear wheel spacing is required for different camber angles and
wheel/tire configurations

Remember that adding camber will affect the overall

footprint of the wheelchair.

52
K0005 Configuration

Caster options

Casters affect rolling resistance, stability, and maneuverability. The

key is to have proper axle adjustment to get most weight through
the rear wheel and decrease rolling resistance.

Caster size
Caster size affects FSTFH and seat angle of the wheelchair.

Small diameter caster Large diameter caster

Lower FSTFH Higher FSTFH

Most WC manufacturers will tell you which available caster sizes will work
when you are selecting the front frame angle and STFH.

The old way of thinking is that large casters roll easier. However, the
correct way of thinking is that less weight on the casters allow them to roll
easier. The key is to decrease as much contact with the ground without
compromising stability, while also having proper rear axle adjustments (rear
COG) to get the most weight on the rear wheel.

The goal is always to minimize rolling resistance.

To achieve this, choose a caster shape and size with the least
contact surface to the ground.

53
 K0005 Configuration

Caster clearance /potential

Casters - too large interference (overhead view)
• May hit the user's feet
• May interfere with the footplate and the
rear wheels

Casters - too small

• May make it difficult to go over obstacles

Casters <6" are less

susceptible to flutter
and provide clearance
for foot rests.
Caster - rear wheel & Larger caster with
https://www.wheelchairstandards.pitt. foot plate clearance forward axle
edu/sites/default/files/fact-sheets/
casterperformanceoverview.pdf

Caster shape
Caster shape is also significant to their ability to roll. The less the caster
touches the ground the less rotational inertia it takes to make the wheel
turn. Most of the time, the wider the caster is, the more contact it has with
the ground. Some styles have a tapered shape so that when on a flat surface
the caster contact point is optimal. Then if the user rolls over a crack or into
a softer surface (e.g. dirt, gravel) they have more surface area to help them
when they need it.

Caster - too narrow

• May be difficult to manage rough terrain
• May have increased risk of getting caught. Example: cracks in sidewalks

Caster forks
Caster forks provide alignment and adjustment features of the casters for
stability, and maneuverability based on client's needs and preferences.
Suspension caster forks provide shock absorption.

54
K0005 Configuration

Additional CRT MWC options

There are a variety of additional options for CRT manual 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
Considerations
options
Handrim and Affect use and propulsion (especially for those with limited dexterity),
wheel lock style otherwise may be heavily dependent on client preference
Affects safe foot placement/positioning
Foot plate style
Options may include rigid, adjustable, swing-away, flip-up, and flip-back
May be needed to promote postural stability
May provide a resting place to reduce fatigue
Arm rest
(optional) Height can affect optimal wheel access
style, height,
Style can affect reaching and transfers
attachment
Options may include: adjustable, swing-away, flip-up, and removable.
Full and desk length
Side guards
(optional) Consider for postural support and stability
adjustable and/or Can provide protection from the wheels during use
removable
Safety feature for some environments and terrain.
Anti-tips
May be fixed, flip-up, removable
Will the client be pushed a fair amount of the time? Can added push
Push handles
handles help them maneuver the WC before and after transfer?
Low seat-to-floor Required for foot propulsion or hemi-propulsion with ultra-lightweight
height or manual tilt-in-space chair
Allows chair occupant to move in/out of posterior tilt in some manual
User-tilt option
tilt-in-space chairs
Allows caregiver to remove the seating system off the base of some
Take-apart frame
manual tilt-in-space chairs for transport

The setup of a CRT 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.

55
 MWC Power Assist

Power Assist

WHAT IS A WHEELCHAIR POWER ASSIST DEVICE?

A power assist device can be added to almost any type

of manual wheelchair to help the user more efficiently
navigate their environment. Power assist devices can
be mounted on rigid, folding and manual tilt-in-space
chairs. Power assist technology can assist in mitigating
risk for upper extremity repetitive stress injury by
reducing the number of pushes required. Power assist
technology can also assist someone who is struggling
to effectively propel their manual wheelchair with hemi-
propulsion.
Refer to Permobil's Power Assist White Paper for a
systematic review of the evidence on all types of power
assist. https://bit.ly/4d9AxwN

Power assist can be hub-mounted, rear mounted, or front

mounted. Hub mounted devices weigh significantly more than
rear mounted devices. 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?

• 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

56
Manual
MWC Power
Wheelchair
Assist Guide

Hub-Mounted
Power Assist
With this style of power assist, the
motors are in the wheels. They Hub-mounted device
are activated through force on (one side visible)

the pushrims. That force triggers

sensors which signal the motors to
propel the wheels forward.

Benefits Considerations
Can be programmed for sensitivity, boost, Adds weight to the wheelchair
and speed (up to 22lbs per wheel)
Wheels need to be removed to facilitate
Very little force is required to activate
transport in a vehicle
Need to protect the wheels during
Assist is on every push
transport, prevent damage to sensors
May offer slope deceleration assist which When the motors are not engaged (short
can help maintain a comfortable speed distances, select environments) the wheels
when going down grades and ramps add weight to every push
Can be used with folding or rigid MWCs If battery dies, adds resistance to wheels
With programming, if there is a strength Modifications to the WC may be necessary
discrepancy from left or right, it may be such as added hardware and increased WC
able to compensate and maintain the width, which could limit access to wheels
desired path and accessibility to narrow spaces
Also require "power adaptable or power
reinforced frame" from manufacturer
Eliminates the ability to use wheel camber
Some users consider adapted vehicles to
avoid removing wheels for transport, which
is a considerable cost

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 MWC Power Assist

Rear-Mounted
Power Assist
This style of power assist is a
detachable, single motor component.
It attaches to the wheelchair axle and Rear-mounted device

wearable devices or controllers signal

the motor via Bluetooth or switches to
start, accelerate, and stop. Turning the
WC is still guided by the user's hands
on the handrims.

Benefits Considerations
Easily removed when transferring MWC into a User must be able to control rate of
vehicle, for transport, and charging descent down grades and ramps
On-demand function. Not necessary to have Disc breaks can be added to the
on the WC when not needed wheelchair to assist with deceleration,
(short distances & around the house) but are a separate device
Acceleration and top speed are Certain amount of training may be
programmable, allows for safe operation required for the user to safely operate
Programmable to meet different needs
Lightest weight option
Freewheels when off or if battery runs out;
minimally increased resistance
Does not compromise configuration of the
wheelchair, which is significant for pushing
without the device
Allows for more user-defined settings for use
in different environments and when selecting
input devices (control via dial, switch, or
Bluetooth wearable)
Weather-sealed / water-resistant
Can be used with folding or rigid MWCs
Can be used with manual tilt-in-space
wheelchairs to help

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Manual
MWC Power
Wheelchair
Assist Guide

Front-Mounted
Power Assist
Front PAD typically have a motorized wheel that is located in front of the
footplate or footrest of a MWC. The system attaches to the front frame of
the MWC and elevates the front caster wheels off the ground. It is then
controlled by a tiller or handle-bar style system with an external motor and
external battery.

Front-mounted device

Benefits Considerations
No pushing required Requires use of tiller for control
Improved access to different environments
Can be challenging to load due to size
because front casters are floating
Braking mechanism May not be as suitable for indoor use
Increased speeds

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MWC Power Assist

60
Conclusion
Manual Wheelchair Guide

Conclusion

WHY IS A MANUAL TILT-IN-SPACE OR

ULTRA-LIGHTWEIGHT CRT MANUAL
WHEELCHAIR 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

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 Quick Guide - MWC Fit

Quick Guide - MWC Fit

Important considerations when completing wheelchair specifications:

• Choose the wheelchair you will use for the evaluation (the client’s existing wheelchair or
demo) – stay with this wheelchair throughout the measuring process
• Measure the demo being used for your records and as a reference for new wheelchair
specifications. Be sure to include overall width and overall frame length – this is the
functional footprint of the wheelchair and may be crucial for the client’s environmental
access and function
• Place the client in the demo wheelchair and ask the client to sit in their most typical and
desired position – the position they are in 80% of the time
• Now you are ready to complete your measurements using the selected wheelchair as a
reference, changing what needs to change for optimal configuration

Below is a model for how to achieve the best fit:

Width Length Wheel access

• Seat width Overall frame length - • Seat-to-floor heights
• Front seat width • Seat depth • Center of gravity
• Footrest width • Frame depth • Camber
• Front frame angle • Wheel spacing

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Quick Guide - MWC Fit

WC width quick reference

Seat width + front seat width + footrest width (standard or V)

Seat width Front seat width (seat taper)

Outside of seat tube at back post to Inside of front frame tube to inside
the outside of the opposite seat tube of opposite front frame tube

Footrest width - Standard Footrest width - V

Inside of front frame tube to inside Inside of front frame tube to inside
of opposite front frame tube of opposite front frame tube 2 ½”
above footrest

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 Quick Guide - MWC Fit

WC length quick reference

Overall frame length = seat depth + frame depth + frame angle.

Using the overall frame length to determine the front frame angle is
the most accurate way of measuring for it.

Overall frame length Seat depth

Front edge of footrest to front edge of Front of back post to front of seat sling
back post

Custom frame depth Front frame angle

Front of back post to beginning of bend Frame front to floor (behind front
frame)

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Quick Guide - MWC Fit

Dimensions & tips

Frame dimension

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

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

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

Footrest width Select a width that allows for adequate space for the client’s feet and
tapers to the client’s desired position
Seat back Select a seat back height that allows the prescribed back support to
height
reach desired height for adequate postural support
Seat back angle Select seat back angle that results in desired support, balance, and
optimal spinal curves when seated
Center of Ideally 80% of the client’s body weight on the rear wheel. Achieved this
gravity
by bringing the rear wheel forward, reducing the amount of weight on
the front casters and improving wheel access
Camber Eases initiation of movement and turns, increases lateral stability and,
therefore, functional width of wheelchair
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

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 Quick Guide - MWC Fit

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

Matching the frame proportionally to the client results in better weight distribution and
unloading of casters, easing propulsion
For best results, your demo should have an ergo seat

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

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
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
Consider transfer style and types of footwear worn

Have your back support demo on the wheelchair

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
Can negatively impact accessibility with adult wheelchairs if >3°

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

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Manual Wheelchair Guide
Glossary

Glossary

Wheelchair & Parts Body & Posture

WC: Wheelchair PPT: Posterior pelvic tilt
WCs: Wheelchairs ASIS: Anterior superior iliac spine
MWC: Manual wheelchair PSIS: Posterior superior iliac spine
MWCs: Manual wheelchairs IT: Ischial tuberosity
STFH: Seat-to-floor height ITs: Ischial tuberosities
PMD: Power mobility device LE: Lower extremity
FSTFH: Front seat-to-floor height LEs: Lower extremities
RSTFH: Rear seat-to-floor height UE: Upper extremity
STBA: Seat-to-back angle UEs: Upper extremities
COG: Center of gravity Process
ELR: Elevating legrest LMN: Letter of medical necessity
Client Function DME: Durable medical equipment
ROM: Range of Motion CRT: Complex rehab technology
ADLs: Activities of daily living POC: Plan of care
Mobility related CMS: Centers for medicare & medicaid
MRADLs:
Activities of daily living services
RR: Rolling resistance People
ATP: Assistive technology professional
MD: Medical doctor/physician
NP: Nurse practitioner
CNA: Certified nursing assistant
PA: Physician assistant

67
 References

References

1. Berner, T., Bernstein, J., Black, J., Cabarle, M., Roesler, T., Scarborough, S., Ott,
J., Worobey, L,. (2023). RESNA Position on the Application of Ultralight Manual
Wheelchairs, Rehabilitation Engineering & Assistive Technology Society of North
America. Assistive Technology, DOI: 10.1080/10400435.2023.2221148
2. Boninger M.L., Baldwin M., Cooper R.A. Gebrosky, B., Bridge, A., O’Donnell, S., Grindle,
G. G., Cooper, R., & Cooper, R. A. (2020). Comparing the performance of ultralight
folding manual wheelchairs using standardized tests. Disability and Rehabilitation:
Assistive Technology, 1-10.
3. Lange, M and Minkle, J. Seating and wheeled mobility : a clinical resource guide. (2018).
Slack Incorporated.
4. Lin, J., Sprigle, S. (2020). The influence of operator and wheelchair factors on
wheelchair propulsion effort. Disability and Research: Assistive Technology.3 (15), 328-
335. doi: 10.1080/17483107.2019.1578425
5. Permobil Department for Scientific and Medical Affairs.(2022). A systematic review of
the evidence for power assist devices[White paper]. https://www.permobil.com/en-us/
clinical-research/research-library/permobil-white-paper-a-systematic-review-of-the-
evidence-on-power-assist-devices
6. Sprigle, S., & Huang, M. (2020). Manual wheelchair propulsion cost across different
components and configurations during straight and turning maneuvers. Journal of
rehabilitation and assistive technologies engineering, 7, 2055668320907819.
7. Sprigle, S. (2023). Measure It: Proper Wheelchair Fit Is Key to Ensuring Function while
Protecting Skin Integrity. Advances in Skin & Wound Care, 36(8), 404-413.
8. Tefertiller C, Jones J, Sevigny M, Dahlin M. Manual Wheelchair Configuration in
Unilateral Upper- and Lower-Extremity Propulsion: A Randomized Crossover Study to
Assess Effects of Rear Wheel Axle Position and Frame Type. Arch Phys Med Rehabil.
2023 Aug;104(8):1188-1194. doi: 10.1016/j.apmr.2023.03.014. Epub 2023 Apr 5. PMID:
37024004.
9. University of Pittsburgh. Fact Sheets on Wheelchair Standards. https://www.
wheelchairstandards.pitt.edu/fact-sheets

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www.permobil.com
[email protected]
1.800.736.0925

2© 2020 Permobil EDU-MWC_GUIDE_REV0822