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Steps to Appropriate Wheelchair Provision

Original Editor - Ilona Malkauskaite as part of the Wheelchair Service Provision Content Development Project

Top Contributors - Ilona Malkauskaite, Naomi O'Reilly, Kim Jackson, Rucha Gadgil, Stacy Schiurring, Robin Tacchetti and Ewa Jaraczewska  

Introduction

Mobility and movement are essential for human health and well-being. For people who rely on wheelchairs for mobility an appropriate wheelchair is a primary need, necessary to ensure physical and mental health and development, function, participation and inclusion. In May 2023, the World Health Organisation (WHO), in collaboration with the International Society for Prosthetics and Orthotics (ISPO) and the International Society of Wheelchair Professionals (ISWP), released updated Wheelchair Provision Guidelines, representing a significant evolution from the 2008 guidelines.[1]

The 2023 WHO guidelines represent a consolidation of wheelchair service provision from the eight steps outlined in 2008 to four core service steps.[1] This streamlining reflects both the development of the sector and the need for greater relevance across all settings whilst maintaining comprehensive service quality.

The original 2008 guidelines outlined eight distinct steps: Referral and Appointment, Assessment, Prescription (Selection), Funding and Ordering, Product Preparation, Fitting, User Training, and Maintenance, Repairs and Follow-Up.[2] The updated 2023 guidelines consolidate these into four essential service steps that begin once a person identifies, or has been identified, as needing a wheelchair and accesses a wheelchair service. These four steps are Select (individual assessment and selection), Fit (preparation and fitting), Train (user and caregiver training), and Follow-up (ongoing review and remediation).[1]

This consolidation does not reduce the comprehensiveness of service but rather integrates related activities, such as referral with assessment and product preparation with fitting, to create a more streamlined, universally applicable framework that can be implemented across diverse resource settings and health system contexts.

The updated guidelines are evidence-based recommendations developed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) framework, designed to address the global challenge of providing wheelchairs to an estimated 80 million people in need. The guidelines are global in scope and provide seven evidence-based service and system level recommendations applicable to all countries, all wheelchair users, and all types of wheelchairs.[1]This Physiopedia Page will overview these updated guidelines.

Table 1.0: WHO Wheelchair Provision Guidelines (2023)[1]
Level of Recommendation Steps
Service Level
  1. Select
  2. Fit
  3. Train
  4. Follow-up
System Level
  1. Competent Workforce
  2. Seamless Referral and Access
  3. Systematic Evaluation

Definition of an Appropriate Wheelchair

WHO defines an appropriate wheelchair as one that meets the user's needs and environmental conditions, provides proper fit and postural support, is safe and durable, is available in the country, and can be obtained, maintained and serviced in the country at an affordable cost.[1] This definition encompasses not only the physical characteristics of the wheelchair but also the broader context of accessibility and sustainability within the user's environment.

An appropriate wheelchair enables mobility, health and function and is also a means by which to exercise human rights. The benefits extend beyond the individual user to their families and communities, facilitating participation in education, employment, and social activities. In contrast, inappropriate wheelchairs can lead to poor outcomes including decreased health and mobility, development of secondary complications, participation barriers, and wheelchair breakdown.[1] For people with spinal cord injuries and similar conditions, inappropriate wheelchairs and lack of proper support can contribute to secondary complications that may cause premature death.[3]

Service Level Recommendations

Recommendation 1: Select (e.g.Individual Assessment and Selection)

Wheelchairs must be provided using a process of individual assessment and selection. This recommendation carries a strong GRADE rating despite low certainty evidence, reflecting the Guidelines Development Group's determination that potential harms of not using individualised assessment and selection can be severe and can result in immediate and large impairments in health, function, mobility, as well as low satisfaction with the wheelchair.[1] World-wide implementation of wheelchair service provision steps supports the feasibility of this recommendation across all resource settings.

Assessment is a comprehensive evaluation of the wheelchair user's physical, functional and cognitive abilities and limitations, environmental requirements across home, work, school and community settings, lifestyle needs and personal goals, postural support requirements, risk factors such as pressure injury and falls, body dimensions and anthropometric measurements, and current mobility status and equipment.[1] This evaluation must be a collaborative process between the wheelchair user and appropriately trained personnel, resulting in a clear understanding of the person's needs to determine appropriate wheelchair features. The assessment process should explore not only current abilities but also anticipated changes, particularly relevant for children experiencing growth and development, or adults with progressive conditions.

Selection involves using assessment information to identify the wheelchair(s), accessories, wheelchair cushion(s) and postural support devices that offer all necessary features identified during assessment, are preferred by the wheelchair user, accommodate postural support and pressure management needs, and enable achievement of activity and participation goals.[1] It is important to recognise that many wheelchair users may require more than one type of wheelchair to meet their full participation needs across different environments and activities. For example, an individual might require both an urban terrain wheelchair and a rural terrain wheelchair, or a combination of manual and powered mobility options depending on their activity demands and energy conservation needs.

The selection process is fundamentally dependent upon product availability. No single model or size of wheelchair can meet the needs of all users, and the diversity amongst users and their needs creates a need for a variety of wheelchair models to be available to choose from. Member States should ensure availability of a range of manual and, where possible, powered wheelchairs, cushions, and postural supports corresponding to the diversity of user needs.[1] Recent evidence demonstrates that mobility device quality plays an important role in participation outcomes, with 20% of all variance in participation reported to come from device quality, specifically repairability, ease of maintenance and reliability.[4] This underscores the importance of not only having options available but ensuring those options meet quality standards that support long-term use and participation.

Recommendation 2: Fit (e.g. Preparation and Fitting)

Wheelchairs must be prepared and fitted for each person based on their individual assessment. This strong recommendation, despite low certainty evidence, reflects the essential nature of proper preparation and fitting to prevent severe harms including immediate and large impairments in health, function, and mobility.[1] The world-wide implementation of wheelchair service provision steps supports feasibility across all settings.

Preparation involves (1) checking that the wheelchair matches specifications from the selection step, (2) inspecting the wheelchair, cushion, and accessories for quality and safety, and (3) making initial adjustments ready for first fitting including backrest height, armrest height, footrest height, rear wheel position, and power wheelchair programming where applicable. In some instances, preparation also includes fabricating custom-made parts or modifications specific to the individual user's needs.[1] This preparation phase is critical for ensuring that when the user first tries the wheelchair, it is safe and as close to optimal configuration as possible, minimising the number of subsequent adjustments required.

Fitting the wheelchair must be carried out with the wheelchair user to ensure that the wheelchair fits as intended and provides them with the required postural support and pressure relief. This process includes (1) verifying proper fit and postural support, (2) checking ability to carry out activities, (3) ensuring compatibility with other assistive technology, (4) confirming usability in home and community environments, and (5) seeking continuous feedback from the wheelchair user.[1] Fitting is often an iterative cycle of adjusting and review that may require more than one appointment to achieve optimal outcomes. Adjustments to one part of the wheelchair may necessitate additional adjustments to other components to achieve final optimal fit, and services must allow sufficient time for this process. For users with complex postural support needs, fitting may involve collaboration between multiple team members and require specialised equipment and materials for creating custom supports.[5]

Recommendation 3: Train (e.g. Wheelchair Skills Training)

Training must be provided for wheelchair users and those who assist them to enable maximum use. The 2023 guidelines provide differentiated GRADE ratings for different components of training. Training in skills to use a wheelchair and use of wheelchair components both carry strong recommendations with moderate certainty evidence. Training in guiding others carries a strong recommendation but very low certainty evidence, while training in wheelchair maintenance and repairs carries a conditional recommendation with very low certainty evidence.[1]

The Guidelines Development Group concluded that the risk of harm associated with not providing minimum training in wheelchair use skills, component operation, and guidance for assistants, combined with the benefits and feasibility of providing training using various low-cost strategies, warranted strong recommendations despite mixed certainty of evidence.[1] The conditional recommendation for maintenance and repairs training recognises that benefits are primarily realised where professional maintenance and repair services are not affordable, accessible, or timely.

Training should address four core areas:[1]

  1. Skills to use a wheelchair encompass transfers to and from the wheelchair, activities while seated such as reaching and repositioning, pressure relief techniques, and operating the wheelchair in all environments.
  2. Use of wheelchair components includes using features such as wheel locks and tilt or recline functions, attaching and detaching components including cushions, armrests, footrests and postural supports, folding and unfolding the wheelchair for transport or storage, and battery charging for powered wheelchairs.
  3. Guiding others involves developing the wheelchair user's ability to determine when and how much assistance is needed, instruct individuals on how to assist safely, and stop people from causing harm when assisting inappropriately.
  4. Wheelchair maintenance and repairs training may include basic maintenance activities such as cleaning, lubricating and debris removal, and simple repairs such as tyre replacement, cushion repair and battery replacement.

Training delivery can take multiple forms, all supported by evidence. Effective delivery methods include (1) in-person training, (2) online methods and video tutorials, (3) single-day intensive training, multi-day or multi-week programmes, and (4) peer-led training approaches.[6][7] [8] Peer-based training has become more prevalent on the premise that peers often share a common culture and ability to share knowledge about problems and challenges experienced, creating belonging and providing opportunity for observational learning.[7] The flexibility in delivery methods allows services to adapt training to available resources whilst maintaining effectiveness.

Training must be customised based on individual needs, considering the type of wheelchair, environments of use, personal goals, ability to carry out tasks independently or with assistance, age and developmental stage, cognitive abilities, progressive or changing conditions, and specific risk factors such as pressure injury or postural problems.[1] For example, children require developmentally appropriate training beginning as soon as they would normally begin exploring their environment, with additional training as they develop their abilities and move into different environments. Older adults experiencing gradual loss of function may need additional training as their function and reliance on the wheelchair changes. People with progressive conditions may need frequent training inputs as their condition changes, potentially requiring different ways to carry out tasks. This individualised approach ensures that training is relevant, achievable and directly applicable to each wheelchair user's unique circumstances and participation goals.

Recommendation 4: Follow-Up (e.g. Ongoing Review and Remediation)

Ongoing follow-up is an integral part of wheelchair service delivery and should be offered and available to all wheelchair users for as long as they require a wheelchair. This conditional recommendation with very low certainty evidence reflects the clinical importance of this service component whilst acknowledging the limited research evidence base.[1] Follow-up provides essential ongoing support to ensure wheelchairs continue to meet users' needs throughout their lifespan of wheelchair use. Follow-up comprises two essential components: review and remediation.

Review involves collaboration between wheelchair user and service provider to identify how well the wheelchair continues to meet needs, changes in the user's physical condition, function or environment, equipment condition and performance, and the need for adjustments, modifications or replacement.[1] This ongoing assessment process is particularly important for wheelchair users whose needs change over time due to growth, development, progression of health conditions, or changes in life circumstances and participation goals.

Remediation involves addressing and resolving identified problems, making adjustments to improve fit or function, arranging repairs or replacement parts, providing additional training as needs change, and referring to other services when appropriate.[1]

The frequency of follow-up should be determined by individual user needs, with priority given to children whose needs change rapidly with growth, users at risk of developing pressure injuries, users with complex postural support needs, and users or carers who experienced difficulty with initial training. As a guide, follow-up appointments are usually made within six months of receiving a wheelchair, though some users will require more frequent contact whilst others may need less.[1] Recent reviews have highlighted the importance of wheelchair maintenance for community mobility and participation, with repair services being one of the often overlooked aspects affecting wheelchair user outcomes.[9][10]

System Level Recommendations

Recommendation 5: Competent Workforce

Wheelchair provision roles must be performed by people who have role-specific competencies. This strong recommendation with moderate certainty evidence underscores that competency, defined as the ability to integrate skills, knowledge, attitudes and behaviours to successfully achieve a desired result, is fundamental to effective wheelchair provision.[1] Fulfilling different wheelchair provision roles requires appropriately trained personnel with specific competencies appropriate to their responsibilities.

Personnel roles in wheelchair provision encompass:[1]

  1. Identification and referral, which involves recognising potential wheelchair users and connecting them to services
  2. Clinical service delivery including assessment, selection, fitting and training; technical service delivery covering product preparation, modifications and repairs
  3. Training provision for delivering wheelchair skills training; and management responsibilities for service coordination, evaluation and quality improvement.

These roles may be fulfilled by different individuals or, in some contexts, combined depending on available workforce and service structure.

Recent evidence on workforce competency has revealed positive correlations between age, years of experience, and performance across assessment, fitting, and user training domains, indicating that accumulated experience contributes to competency development.[11] This highlights the importance of both initial training and ongoing professional development to build and maintain competencies over time. The Wheelchair Educators' Package, an online resource developed by experts from 21 countries and launched in 2022, provides guidance for educators on planning, teaching and evaluating wheelchair service content to support integration of wheelchair service training into university and workforce preparation courses.[1]

Recommendation 6: Seamless Referral and Access

Wheelchair provision including identification of need, referral and service delivery should be seamless and integrated across all levels of health systems and other relevant sectors. This strong recommendation, despite very low certainty evidence, reflects the critical importance of system coordination for achieving equitable access to wheelchair services.[1]

Seamless wheelchair provision is characterised by consistency, continuity and coordination of identification, referral and service steps in a timely manner with minimal barriers and delays. Integration means wheelchair provision is part of comprehensive health service at all levels, from primary through to tertiary care, and as appropriate, other sectors such as educational, vocational or social welfare services.[1] Effective seamless provision requires clear referral pathways between services and sectors, defined criteria for referral to different levels of service, task-shifting strategies to mobilise the required workforce, coordination between governmental and non-governmental services, outreach models and telehealth to bridge distance gaps, and well-communicated processes across all stakeholders. This systematic approach ensures that wheelchair users can access appropriate services regardless of where they first present in the health or social care system, and that their journey through the service pathway is as smooth and efficient as possible.

Recommendation 7: Systematic Evaluation

Processes to measure and evaluate the performance of wheelchair provision should be implemented to inform ongoing strengthening of people-centred, equitable access to appropriate wheelchairs. This conditional recommendation with very low certainty evidence emphasises the importance of continuous quality improvement through systematic data collection and evaluation.[1]

Measurement includes (1) routine collection of information about service users encompassing demographics, needs and outcomes; (2) personnel including numbers, competencies and training needs; (3) provision processes covering efficiency, timeliness and quality; and (4) products provided including types, appropriateness and durability.[1]

Evaluation involves (1) reviewing collected information, (2) determining whether provision meets, exceeds or falls short of targets, (3) identifying strengths and weaknesses, and (4) generating recommendations for improvement.[1]

Strengthening means (1) making changes when evaluation indicates weakness, (2) building on successes, (3) implementing continuous quality improvement processes, and (4) informing policy development and resource allocation.[1] A 2023 systematic review of measurement properties for wheelchair outcome measures in persons with spinal cord injury identified that the Wheelchair Outcome Measure and Wheelchair Skills Test Questionnaire show the current best potential to be recommended for clinical and research use, providing validated tools that services can utilise in their evaluation processes.[12]

Implementation Considerations

For Rehabilitation Professionals. Rehabilitation professionals require comprehensive clinical competencies to effectively deliver wheelchair services. These include comprehensive assessment skills across physical, functional, environmental and psychosocial domains; knowledge of wheelchair products, features and their functional implications; fitting and adjustment skills; training delivery abilities; ability to work collaboratively with multidisciplinary teams; and understanding of progression pathways for users with changing needs. Evidence-based practice integration is essential, requiring professionals to use validated assessment and outcome measures,[12] apply systematic training programmes with demonstrated effectiveness,[6] document outcomes to contribute to service evaluation, and engage in continuing professional development to maintain and enhance competencies throughout their careers.

For Service Managers. Service managers play a critical role in system strengthening. Priorities include establishing clear referral pathways that connect wheelchair users to appropriate services at the right time, ensuring availability of appropriate product ranges that meet the diversity of user needs, and investing in workforce training and development to build and maintain competency across the team. Managers must implement systematic data collection and evaluation processes to enable continuous quality improvement, develop policies supporting all service steps from initial assessment through to long-term follow-up, and advocate for adequate, sustainable funding that supports comprehensive wheelchair provision rather than fragmented or inadequate services. Creating a culture of quality, equity and person-centred care requires leadership that prioritises these values and embeds them in service operations and evaluation.

For Educators. Curriculum development in rehabilitation education must integrate wheelchair provision content into entry-level programmes to ensure all graduates have foundational competencies in this area. Utilisation of evidence-based educational resources such as the Wheelchair Educators' Package provides structured guidance for teaching wheelchair service content.[1] Hands-on practical training opportunities are essential for developing skills that cannot be learned through theory alone. Including wheelchair users' perspectives and lived experience in educational programmes enriches learning and promotes person-centred practice. Assessment of competencies using validated tools ensures that graduates meet the standards required for safe and effective practice, while also identifying areas where curricula may need strengthening.[11]

Conclusion

The 2023 WHO Wheelchair Provision Guidelines represent a significant advancement in establishing evidence-based, globally applicable standards for wheelchair service delivery. The consolidation from eight to four service steps (Select, Fit, Train and Follow-up) combined with three system-level recommendations (addressing Competent Workforce, Seamless Referral and Access, and Systematic Evaluation) provides a streamlined yet comprehensive framework for ensuring access to appropriate wheelchairs. This evolution reflects both the maturation of the wheelchair provision field and the accumulation of evidence demonstrating what works in diverse contexts and resource settings.

For rehabilitation professionals involved in wheelchair provision, these guidelines provide clear, evidence-based direction for clinical practice while emphasising the critical importance of individualised, person-centred service delivery. The guidelines highlight the necessity of competency-based training and ongoing professional development to maintain and enhance the skills required for effective wheelchair provision. They underscore the need for systematic evaluation to drive continuous improvement in service quality and outcomes. Perhaps most importantly, the guidelines position wheelchair provision as an essential component of universal health coverage and human rights, elevating it from a specialised technical service to a fundamental health and social requirement.

Implementation of these guidelines will support progressive realisation of the Convention on the Rights of Persons with Disabilities and contribute to achieving the Sustainable Development Goals, particularly those related to health and well-being through SDG 3, inclusive education through SDG 4, and reduced inequalities through SDG 10.[1] By providing a clear framework grounded in evidence and expert consensus, these guidelines offer rehabilitation professionals, service managers, educators, policy makers and advocates the tools needed to strengthen wheelchair provision systems and ultimately improve the lives of the millions of people worldwide who rely on wheelchairs for their mobility, participation and independence.

Resources

Clinical Resources:

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 World Health Organization. Wheelchair provision guidelines. World Health Organization; 2023 Jun 2.
  2. ↑ World Health Organization. Guidelines on the provision of manual wheelchairs in less resourced settings. World Health Organization; 2008 Dec 31.
  3. ↑ Hogaboom NS, Worobey LA, Houlihan BV, Heinemann AW, Boninger ML. Wheelchair breakdowns are associated with pain, pressure injuries, rehospitalization, and self-perceived health in full-time wheelchair users with spinal cord injury. Archives of physical medicine and rehabilitation. 2018 Oct 1;99(10):1949-56.
  4. ↑ Gallagher A, Cleary G, Clifford A, McKee J, O’Farrell K, Gowran RJ. “Unknown world of wheelchairs” A mixed methods study exploring experiences of wheelchair and seating assistive technology provision for people with spinal cord injury in an Irish context. Disability and Rehabilitation. 2022 May 8;44(10):1946-58.
  5. ↑ Beauregard TA, Schein RM, Berner TF, McKernan G, Schmeler MR, Dicianno BE, DiGiovine CP. Investigation of stakeholder perceptions of the wheelchair service delivery process. Disability and Rehabilitation: Assistive Technology. 2025 Jan 11:1-9.
  6. ↑ 6.0 6.1 Keeler L, Kirby RL, Parker K, McLean KD, Hayden JA. Effectiveness of the Wheelchair Skills Training Program: a systematic review and meta-analysis. Disability and Rehabilitation: Assistive Technology. 2019 May 19.
  7. ↑ 7.0 7.1 Charlton K, Murray C, Layton N, Ong E, Farrar L, Serocki T, Attrill S. Manual wheelchair training approaches and intended training outcomes for adults who are new to wheelchair use: A scoping review. Australian Occupational Therapy Journal. 2025 Feb;72(1):e12992.
  8. ↑ Chase T, Mendoza K, Rager C, Stiens M, Loeser M, Stead T, Kozlowski W, Van Antwerp L, Camilleri J, O’Neil J. Skills on wheels: initial pre-post findings from a pilot study of a pediatric wheelchair skills training program. Disability and Rehabilitation: Assistive Technology. 2024 Nov 16;19(8):2945-52.
  9. ↑ Mhatre A, Zhao M, DiGiovine C, Berner T, Gauen E. Identifying risk factors for wheelchair damage, part failure, and adverse consequences to the user. Disability and Rehabilitation: Assistive Technology. 2025 May 19;20(4):1027-34.
  10. ↑ Hiles KM, Schein RM, Pramana G, Schmeler MR. Wheelchair user’s perceived access to maintenance and repair services: a qualitative study. Disability and Rehabilitation: Assistive Technology. 2025 Jul 4;20(5):1351-9.
  11. ↑ 11.0 11.1 Burrola-Mendez Y, Goldberg M, George CJ, Kirby RL, Rushton PW, Terhorst L, Pearlman J. International Society of Wheelchair Professionals’ Basic Manual Wheelchair Service Provision Knowledge Test Version 2: Assessment of preliminary psychometric evidence. Assistive Technology. 2025 Feb 14;37(sup1):S18-26.
  12. ↑ 12.0 12.1 de Freitas GR, Abou L, de Lima A, Rice LA, Ilha J. Measurement properties of clinical instruments for assessing manual wheelchair mobility in individuals with spinal cord injury: systematic review. Archives of physical medicine and rehabilitation. 2023 Apr 1;104(4):656-72.
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