Identifying your needs

For someone who requires a wheelchair all or much of the time, you should access a full seating assessment from an occupational therapist or physiotherapist skilled in this area of work. If you have specialist needs it is vital that you have a professional assessment in order to get the correct chair and seating. You can be referred to your local wheelchair service via your GP or another healthcare professional.

Even if you do not require a professional assessment, it is important to recognise what your requirements are, in order to get the right wheelchair to help you in your circumstances.

There are a number of factors about yourself to consider including:

Your mobility 
This is your ability to move around. It includes walking, sitting down and standing up and adjusting or moving your body within the chair. Depending on your level of ability, you will need to consider how you will get in and out of the chair. Are you able to walk short distances? Are you able to stand up and sit down safely? Will you need to transfer, perhaps using a transfer board? Does the chair have removable armrests allowing you to do this? Are you usually hoisted? Will the chair enable your hoist to move close enough to the chair to enable this?

Your tolerance 
This is the length of time you can tolerate doing something, e.g. standing, walking or sitting.

Your balance 
This is your ability to remain steady, when standing, when seated and especially when moving between the two.

Your posture 
This is the position in which you hold your body. When using a wheelchair you need to be able to maintain a comfortable, stable, safe and supported seated position. You may need special cushions or support to provide comfort and help you to maintain your position, especially if your sitting tolerance is poor.

Your body height and weight
if you are a very tall or large person you will need to look for a wheelchair that is appropriate and safe for you. Measure and record your height and weight accurately and check manufacturers’ details. A tall person will need a chair which can support longer legs, a longer spine and possibly bigger feet - your limbs and body should be fully supported when in the chair. It is important for a large person to have a chair which is designed and made for their body weight and size so as to maintain the correct balance and stability in the chair, and to prevent discomfort and pressure areas and to ensure the chair does not break.

Your skin condition 
Is your skin that is on any potential pressure points intact and healthy? The relevant pressure points might be the bony prominences of your bottom and hips, the base of your spine and the back of your knees. Any areas upon which you lean without relieving the pressure has the potential to develop a pressure ulcer, such as your shoulder blades and elbows or forearms. If you are going to spend significant time in the chair and if you find it difficult to relieve the pressure on these areas by shifting around, you must obtain suitable pressure relief cushioning.

Your sight, perception, memory and cognitive ability 
if you are losing your visual, perceptual, memory or cognitive abilities, it is unlikely that a self-propelling manual chair is appropriate for you, but an attendant controlled chair could be more suitable.

All of the above can be affected by many things including age, tiredness, a medical or physical condition and medicines.

Consider how all these factors will be affected by, and will affect, your use of the wheelchair.

If you have a condition which is deteriorating, you may wish to take account of your possible future needs at this earlier stage. You also need take into account the abilities and needs of any person who will be helping you, including possibly lifting the chair and carrying out basic maintenance tasks.

Getting in and out of the chair

Your remaining level of mobility may dictate how you get in and out of the chair and which features you may need as part of the chair. If you can still walk short distances and can stand up and sit down, you will be able to manage getting in and out of the chair without assistance.

Remember – however you transfer, you must ensure that you put the wheelchair brakes on before you get in or out of the chair.

Most chairs have removable armrests which may be useful to you if you slide transfer - perhaps when moving to and from a car or the bed.

Every chair will have footplates which either swivel or flip up out of the way. It is important that you take the time to move the footplates out of the way before you get in or out of the chair. If not, they become a trip hazard or you run the risk of tipping the chair should you put your whole weight upon them.

If you require a hoist to be transferred in and out of the chair, you need to ensure that your hoist and the chair that you choose will work together. The base of the hoist will need to span the overall width of the chair - or be able to move underneath it - getting close enough to correctly position you into the seat.

Choosing a wheelchair for your body shape and size

A wheelchair should add to your freedom and independence; it should enable your comfort and well-being and not limit your body movement or cause pain or pressure ulcers.

If your body shape allows, you want to preserve and support good posture by:

• keeping your head, neck and spine aligned
• keeping your pelvis, hips and knees aligned
• choosing suitable support cushioning.

Avoid creating pressure points or limiting your movement within the chair by:

• ensuring that the chair seat, back and shoulder rests are the right size for you
• allowing for a little space either side of your bottom and thighs
• avoiding the use of lumpy cushions or wearing any bulky clothes which create pressure points when you are seated in the chair
• choosing an appropriate pressure relieving cushion.

A wheelchair is a bulky object and can be longer than it is wide. It is designed to be as safe and balanced as possible, especially when moving over uneven or sloped surfaces.

A chair can be provided to accommodate a person’s individual body size, shape or requirements and their level of ability. For example, when a person loses a lower limb, their centre of balance changes, even when seated. The balance of the chair has to be adjusted, moving the rear wheels of the chair backwards, to prevent it tipping. If you are a fit, active user the rear wheels can be moved forward to enable more efficient propelling and turning, but it can potentially be less stable.

If you have significant personal requirements in terms of your body size, shape or mobility you are advised to seek professional assessment and advice through your local wheelchair service.

Measuring for your chair

You should not be ‘squeezed’ into the chair, but have enough space to move within the seat, to rotate your upper body if possible and move your arms. Yet you also need to be supported, especially if you find maintaining your posture tiring and difficult.

You will need help to gain accurate measurements of yourself. Make sure you are seated comfortably and well-supported, with your back as straight as possible and with your hips at 90 degrees (a right angle) and your feet flat on the floor. Wear your normal clothing and shoes. If you have complex seating needs, you may have to adapt these measurements and you are then advised to seek professional advice.

Measure and record these distances (in centimetres). You may not use all of them, it is dependent on the level of support you require from your chair:

(a) Seat width (not the overall width of the chair)
The distance between the widest part of your hips or thighs, plus a maximum of 2cm either side. The seat/backrest width should give you enough room for winter-weight clothing, but not be so big that it causes you to lean sideways to find support. This is particularly important if you have poor upper body strength and control. Neither should you struggle to reach over the arm rests to reach the wheels. So if, when seated, the widest part of your bottom or hips measured 42cm across, you should be looking for a chair seat with a width of approximately 46cm (18”).

(b) Seat depth 
The distance between the back of your bottom to the back of your knee, minus 2cm. If you have a discrepancy in your leg length, take the measurement from the shorter leg. So if, when seated, the distance between the back of your bottom and the back of your knee is 46cm, you should be looking for a chair seat with a depth of 44cm at most (17.5”). If you choose a larger depth it will cut into the back of your knee.

(c) Armrest height
The distance between the seat and your elbow when bent at an approximate right angle (as if resting on the chair arm). Make sure you are not leaning to one side.

(d) Lower leg length and seat height
The vertical distance between the back of the knee to the heel of the shoe. This gives the distance from the wheelchair seat to the footplates. Add 4cm to give the total seat height from floor to seat. If you have long legs you may require the foot plates to be angled further out, preventing your feet from getting in the way or catching on obstacles.

(d) Back width
The widest distance across the back, just below the armpit. The backrest on a manual chair is generally the same width as the seat. If your back is very much broader than your hips/thighs and you need back support at a higher level, you may have to consider having a wider chair, or a more specialist back rest.

(d) Back rest height
This will depend on how much support is required. For people with good body strength a shorter back rest will be necessary. Take the following measurement according to the level of support you require:

• i. The vertical distance between the seat surface to bottom of the scapula (shoulder blade), if you are able to sit comfortably with minimal back support.
• ii. The vertical distance between the seat surface and the top of the shoulder, if you need support all the way up your spine.
• iii. The vertical distance between the seat surface to the bump on the back of the head, if you require head support also.

Manual wheelchairs

Manual wheelchairs can be either self-propelled or attendant-propelled.

Self-propelled chairs require the user to use their upper limb, body and grip strength to move the wheelchair, usually by grasping the wheel rims and moving the wheel, and thereby the chair, in the chosen direction. There are alternative ways of propelling a chair which are described below.

Attendant-propelled chairs require another person to push the chair from behind, using handles at the rear of the back support. If you are obtaining an attendant-propelled chair, ensure your carer is fit and strong enough to push the chair and manage obstacles such as kerbs.

Self-propelled chairs have large rear wheels for the user to grasp and push. Attendant-propelled chairs have much smaller rear wheels. This means that the self-propelled chairs tend to give a smoother ride as the large rear wheels better span lumps and bumps in the road/floor surface. If you are privately buying or renting a chair, you may wish to consider this, irrespective of who will propel the chair.

Propelling the chair

Double hand rim
This is designed for people who only have the use of one arm/hand. It has both hand rims on the same side of the wheelchair, but controls the rear wheels on both sides. The inner hand rim is connected to the far wheel by way of a bar or scissor mechanism between the hand rim and the wheel.

When propelling the wheelchair in a straight line, the user grips both hand rims in one hand equally and pushes or pulls the hand rims in the direction they wish to travel. To turn the wheelchair, the user will push or pull on one rim more than the other. Double hand rim controls require good grip, hand strength and dexterity.

Lever drive systems
This has a lever attached at the front of the chair, with linkages to the rear wheel. The user ‘pumps’ the lever back and forward to drive the chair. - this is attached to the forward, neutral and reverse settings. To steer, the user turns the lever in the direction that they wish to travel.

The user requires grip and the physical stamina to pump the lever, along with the ability to consider steering and pumping at the same time.

A single lever can be used by someone with the use of only one arm/hand. A dual level drive system is available. The user pushes and pulls each side alternately. It requires significant strength and stamina.

Using your foot to propel the chair
Some people choose to propel themselves in the chair by using their feet, or one foot, to scoot across the floor surface, whilst using the wheel rims to assist with steering. This can work for those who have good leg and foot strength and perhaps have less pushing strength in their upper limbs.

If you choose to self-propel with your feet, you will require a chair with a lower seat so that you feet fully reach the floor. You may also benefit from a lap strap or harness to keep you safely in the chair.

Pedal attachment
Attachments are available which in effect turn the wheelchair into an adult tricycle. The pedal mechanism can be used by the feet or hands, depending on your ability. The chair is steered via the handlebars, just like a bicycle. Most users will require assistance fitting these attachments. Once attached, transfers in and out of the wheelchair are only possible by very able users.

Pedal attachments are also available with power-packs.

Converting a manual chair to a powered chair

It is possible to obtain a powerpack which attaches to a manual chair, in effect adding a motor. They are fitted very easily and offer a full conversion to a powered chair with a joystick; or giving a level of assistance, which takes some of the strain out of manually driving a chair, or for the carer pushing.

You can still choose to manually drive your chair for periods, even when they are fitted.

Most manual chairs can be fitted with a powerpack. Depending on the drive mechanism, some units require particular wheels to be fitted to your chair and some require an anti-tipping mechanism to be added.

Training and safety

Most people can instinctively manoeuvre a manual wheelchair in a simple way, but some people can find it difficult. It is worth practicing propelling and turning techniques, getting over obstacles, tackling kerbs and thresholds etc in a safe environment before venturing outside.

Some statutory wheelchair services will provide basic training upon provision of a chair.

There are also a number of commercial companies or support organizations which provide fuller training, for example Backup Trust, the spinal injuries charity, provide group training to both a basic and more advanced level.

Training and safety for children

Children who receive a wheelchair from the NHS wheelchair service will receive basic training in the safe use of the wheelchair. Further training is recommended though, to allow children to reach their full potential with wheelchair skills. 

Reclining and tilt in space wheelchairs

Wheelchairs are available which have the ability to recline or tilt in space. These would help someone who has weak upper body strength or experiences back and/or hip pain and needs to rest.

These are two separate movement mechanisms. The reclining chairs have a back which reclines, but the seat remains static. Elevating leg rests may be required to make this a comfortable option. Tilt in space chairs tilt the back and seat backwards as one unit, keeping the same angle at the hips, knees and ankles.

When either of these mechanisms is used, the chair becomes very long and not very manoeuvrable. Consider what space will be required when used inside. Look to see how these mechanisms are operated - can they be used by the person in the wheelchair, or will help be required? Can they be operated when the user is in the chair?

High performance chairs

These are the lightest and most manoeuvrable chairs available. They are designed to require less effort to propel or push, so are often used for sport. High performance chairs are low-backed and tend to give minimal side support. The rear wheels are larger and may be angled to assist with propelling. They are often very adjustable to meet individual needs and preferences.

Practical considerations

Servicing and maintaining your wheelchair

If you have an NHS chair, it will normally be fully maintained and repaired through the wheelchair service.

There are a number of things that you can do to maintain your chair:

• Manual wheelchair tyres are very similar to bicycle tyres. Punctures are not uncommon. Check they are kept at optimal pressure (look at the manufacturers advice) and check the tyres for wear and tear
• Check the brakes. The chair needs to be securely held by the brakes as you get in and out of it. Ensure that when the brakes are applied, the wheels do not move
• Keep the wheelchair clean and regularly oil the axles and pivot points
• Regularly check any nuts and bolts to ensure that they are secure
• Periodically check the frame for damage or cracks, especially if the chair gets heavy usage.

A regular service will ensure that your wheelchair is safe. Check the manufacturer’s or supplier’s instructions.

Getting your chair into a car

Most manual wheelchairs are able to fit into a car, enabling you to take it with you when you travel. Your chair may have a folding frame, with a fold down backrest, removable footrests etc, or it may have a rigid frame, but with removable wheels.

The chairs are heavy to lift, so there are a range of options for getting them into a vehicle, including ramps, lifts and hoists.

Footrests

The footrests on a chair should be used at all times when sitting in the chair, but should be moved out of the way when transferring in and out of the chair.

Footplates usually swivel to the side and flip up out of the way. Your feet should not ‘dangle’ but be supported by the footplates, preventing all the weight of your legs being carried on the back of your thighs. They should be at least 4cm clear of the ground.

There are usually heel straps attached to the footrests which cup your heels and prevent your feet slipping backwards. These can be removed if you find them inconvenient. This may occur if you have particularly big feet.

Elevating leg rests

Elevating leg rests support the lower leg in a raised position. The leg rest is supplied in place of a footrest. Care should be taken when mobilising or pushing a wheelchair with the user’s legs raised, as it can make the legs and feet quite vulnerable to being knocked.

Armrests

Most wheelchairs can accommodate a choice of arm rest designs. They can be full length or desk style (shorter). They may be height adjustable. Some are detachable, fold up and/or down or swing away.

If you have good torso strength and stability, you may prefer to have less support and use shorter armrests. This can give more freedom of movement in the upper body and arms. It also means you can move the wheelchair closer in to tables and desks. If you have less upper body stability, you are better off getting good support from the armrests.

The armrests should support your forearms without the need for you to hunch your shoulders or lean to the side. They should be padded, so not to cause pressure points along your forearms.

Consider how you will be getting in and out of the chair. Will you need a full-length armrest to support yourself as you sit into the chair or up from the chair? Do you need removable or movable armrests if you transfer sideways in and out of the chair?

Look at the manufacturer’s website, or ask the supplier for information on what options are available.

Cushioning and support when seated

Most standard wheelchairs will come with a padded seat or a basic seat cushion. If you are using your chair much of the day, this may not offer enough pressure relief, even for someone who has good skin condition. You are advised to consider obtaining a cushion which offers an element of pressure relief. Look at the manufacturer’s information or ask your dealer.

When you are seated in the chair, aim to keep your body as aligned as possible and not leaning to one side.

Moulded cushions can help to maintain the hips and pelvis in good alignment. You can obtain chair inserts and cushioning which offer support at particular points if required.

If you struggle to maintain an upright posture, you may benefit from support around your torso. Look for a backrest or cushion which is shaped, curving around your back and slightly under your arms at the back.

There are a range of cushions, backrests and mouldable supports that fit into a wheelchair leaving the existing seat and backrest in place. If you need active support, look for an insert that is more rigid (although it will need a soft outer covering). If you just want comfort, look for a soft padded insert or cushion.

It may help you to maintain an upright posture if you have a belt or harness, which also adds an element of safety. You can have a lap strap or hip belt, as you would wear in an aeroplane, or a higher strap across your tummy. These can be padded for extra comfort. More support can be given by a chest harness which secures you around your torso and over your shoulders. You can also add a crotch strap. You are advised to seek professional advice before you use a full harness, as they can create pressure points and distort a person’s posture if poorly fitted.

It is important to remember that straps and harnesses should not be used for the sole purpose of restricting a person’s freedom when they lack capacity to understand or make choices. Harnesses can be used to restrain a person when the purpose is to prevent them harming themselves.

If you have complex positioning needs, seek the advice of a seating specialist.

Portable ramps

You may need ramps to be able to enter or leave your home when on your wheelchair.

You can choose whether to create a permanent ramp or to use portable ones.

Ensure that the ramps can bridge the change in levels adequately, without creating too steep a slope and check the weight capacity of the ramps. Check that the ramps can accommodate the width of your wheelchair and the combined weight of the wheelchair and your body.

As a general rule most ramp manufacturers recommend a gradient no steeper than 1:12 for independent use and 1:10 for assisted use. A simple calculation for finding out the right ramp length is to multiply the height by the ratio - i.e. if working on a 1:12 ratio multiply the height of step by 12 to give you the minimum length of ramp, e.g. 6″ step x 12 = 72″ (6ft ramp).

Accessories

Walking stick or crutch holders
Clips are widely available to hold walking sticks, crutches etc.

Most combine a clip with a cup to hold the base of the stick or crutch. They attach to wheelchairs with a variety of fastenings including screw clamps or hook and loop Velcro. Some are fitted behind the chair, others to the side.

Consider the most appropriate fitting for your chair and your ability to reach to guide your choice. Ensure that the clip element of the holder is big enough for your stick or crutch.

Drinks holder
There are a range of cup, bottle and drink holders available. These attach on to the frame of the wheelchair and allow you to carry a drink around with you.

Wheelchair umbrella
A wheelchair umbrella clamps to the wheelchair frame and has a flexible handle to enable positioning. Clamps are also available into which a standard umbrella can be fixed.

Bags
There are a range of bags available specifically designed to attach to a wheelchair. Most attach to the back of the chair, but others fit to one side, as pannier bags, or under the seat.

Consider the design of your chair and your ability to reach the bag when seated in the chair.

A number of other specific bags and holders are also available, such as ones for carrying mobile phones, wallets or oxygen cylinders.

Wheelchair outdoor clothing

Wraps, capes, ponchos and macs 
When you are sat in a wheelchair, it is easier to put on or take off and wear an outer layer which is loose fitting. Wraps, capes and ponchos are easy to slip around or over your head.

The looser fit across the shoulders and upper arms is more comfortable as you self-propel your chair. Large capes and ponchos are available in waterproof fabric, acting like a mac in wet weather. They can be large enough to cover both you and the chair.

Leg cosy 
A leg cosy or zipped sitting bag keeps your legs warm and protected from wet or windy weather. These are designed to be used instead of having a blanket over your legs, as blankets can get caught up in the wheels of your wheelchair.

Tables, trays and stands
Wheelchair tables and trays come in a variety of sizes and designs. Some fit across the whole lap space, attaching to both sides of the chair, others are a half-lap size, fitted to one side, which flip over to be used or stored at the side.

Most people would need assistance in fitting a full width wheelchair tray once in the chair. A half-lap size can usually stay in situ, flipped over and stored down the side of the chair.

Most trays have a smooth wipe-clean surface with a raised edge. Some are moulded or have a cut-out circle to accommodate a cup or mug. An increasing number are made of see-through polycarbonate, which enables the user to see what’s in front at floor level. Padded trays are also available.

Small stands are available which clamp to one side of the wheelchair frame. With a flexible arm, these can hold books or a tablet.
 

Provision of wheelchairs

Statutory provision

Wheelchair services are funded through the NHS, although they may be sub-contracted to a local company.

You will need a referral from your GP or another healthcare professional who can identify your current level of mobility and the need for a chair. Each locality may be different with its own eligibility criteria and waiting times. They will only provide chairs to people with long-term (more than six months) mobility and associated postural management needs. The chairs are provided as an aid to mobility and independence. Chairs for rehabilitation, sporting or other purposes are not usually provided.

Some wheelchair services or local hospitals will provide wheelchairs on loan in certain circumstances, for example following surgery.

You are advised to contact your local wheelchair service to clarify their criteria for provision and their waiting time.

Once referred you should be assessed, usually by an occupational therapist or physiotherapist. If your mobility or postural management needs require a very specific chair, you may also be seen by a mobility engineer who can custom-build a chair according to your requirements. The professional carrying out the assessment may ask you about your home or any other environment which you will need to access in the chair, your work for example.

Following the assessment, the statutory wheelchair service will usually offer the provision of a wheelchair in one of the following ways:

• a wheelchair supplied to meet the needs identified by the assessment, fully funded by the service and fully maintained and repaired by the service
• a voucher to the value of the appropriate wheelchair, allowing you to top-up and purchase a wheelchair in line with your preferences from a limited menu of options which are additional to the assessed need. The wheelchair is owned, maintained and repaired by the service and will be purchased by the service
• a voucher for the amount of the appropriate wheelchair plus contribution toward repair and maintenance, allowing you to top-up and purchase a wheelchair in line with your preferences which are additional to the assessed need. The wheelchair is purchased, owned, maintained and repaired by you. The wheelchair service will usually advise on reputable wheelchair suppliers
• Some areas allow the voucher to be used to rent a wheelchair on a long-term basis. This includes insurance, maintenance and repairs.

Some areas are trialling a personal wheelchair budget, which would replace the voucher scheme. The intention is to give people who use NHS wheelchair service greater choice and control. The budget can be used to buy a chair from within the NHS range that is available locally, or they can add to the budget to enhance what is available from the NHS, or to buy privately.

If a wheelchair is agreed and provided by the service, they will also provide accessories based on the assessment of your needs, basic advice in the use and care of the chair and a repair and maintenance contract. The repair and maintenance is usually provided by a local mobility engineering company.

If you, or the person you care for, are in receipt of continuing care funding, you are unlikely to have a chair funded through the wheelchair service, although they may provide the assessment.

Private purchase

You may want an assessment from a private or independent occupational therapist. The Royal College of Occupational Therapists has a list of available practitioners which you can access online.

There are numerous wheelchair retail companies. Your local NHS wheelchair service may be able to make some recommendations. Some suppliers will offer an assessment of your needs. Be certain of your preferences and requirements before you look at any wheelchairs, so that you are not encouraged or tempted to buy something which will not actually meet your needs. You are advised to try a number of models before you purchase. Remember your environmental needs and your carer’s needs also. Where will the chair need to access? Where will you store it when not in use? Ask the supplier about ongoing maintenance, repair and insurance.

Many retailers are members of the British Healthcare Trades Association (BHTA), which means that they adhere to the organisation’s code of practice. You can search the BHTA website for local retailers.

Equipment Demonstration Centres
If you need advice before you buy, contact your local equipment demonstration centre where you will have the opportunity to try out a range of equipment. There are several of these around the country where you can go for impartial advice. Your local authority will also be able to supply information about where your nearest centre is located

VAT relief
If you have a diagnosed long term condition, you should be able to claim VAT relief when purchasing a wheelchair. Ask the supplying company or check their website for further information. 

British Standards
Manual wheelchairs are covered by the British Standard BS EN 12183:2014. Manual wheelchairs. Requirements and test methods (British Standard Institution. 2014).

Access to Work

Access to Work provides grants for practical assistance if you have a disability, health or mental health condition, in order to help you gain employment, stay in employment, or even become self-employed. Access to Work may provide funding for a wheelchair if it is required for the purposes of your work and there is no more cost-effective alternative. If you meet the criteria to get a chair from your local wheelchair service, Access to Work may not provide funding. You will need to contact your local Jobcentre Plus.

Charity funding

There are a number of trusts and charities that will consider funding wheelchairs. Disability Grants' website list charities and Trusts that provide funding towards disability equipment.

Second hand equipment

There is a large market in second hand mobility equipment, including schemes run by commercial suppliers. There is some advantage to using a recognised company as most offer wheelchairs which have been serviced or reconditioned and have a short warranty or service agreement.

If you are buying a second hand chair from a private individual, ensure you are given the accompanying literature, an instruction manual and any service history.

If it is a folding wheelchair, check that it folds and unfolds smoothly. Look at all nuts and bolts – check that they are present and secure. Ensure the tyres are in good condition and that the brakes work well. The seat should not sag and the backrest should have no more than a gentle curve to it. All stitching should be in good condition.

Hiring a manual wheelchair

There are numerous national and more local companies who offer manual wheelchairs for hire. Some offer an international service. Most charge for the service and require a deposit which is returnable upon the return of the chair. It is important that you know your requirements before you hire a chair, especially your weight and body size. Perhaps the most important dimension is the width across the widest part of your hips or bottom, as this will determine the most appropriate wheelchair seat size.

Most companies offer a range of sizes, including children’s chairs and bariatric chairs (for heavier people). Larger companies offer chairs with elevating leg rests and tilt in space mechanisms. You are advised to enquire what cushions are provided or available.