Wheelchair Maintenance

Original Editor - Mariam Hashem as part of the Wheelchair Service Provision Content Development Project

Top Contributors - Naomi O'Reilly, Mariam Hashem, Kim Jackson, Simisola Ajeyalemi, Stacy Schiurring, Vidya Acharya, Shaimaa Eldib, Rucha Gadgil, Amrita Patro, Olajumoke Ogunleye and Robin Tacchetti  

Introduction

Wheelchair maintenance and care are essential components of comprehensive wheelchair service delivery. The World Health Organization's (WHO) 2023 Wheelchair Provision Guidelines present a framework consisting of four service-level steps and three system-level recommendations. The four service-level steps are: (1) Select, (2) Fit, (3) Train, and (4) Follow-up. These steps consolidate the previous 8-step process to ensure greater relevance across all settings and reflect the development of the wheelchair provision sector. The three system-level recommendations address: (1) Competent workforce with role-specific competencies, (2) Seamless referral and access to services across the health system, and (3) Systematic evaluation of wheelchair services.

Maintenance is embedded within all seven steps. This integrated approach ensures wheelchairs continue to meet users' needs, prevents product abandonment, and reduces the risk of secondary injuries.

Effective maintenance ensures wheelchairs continue to meet users' needs, prevents product abandonment, and reduces the risk of secondary injuries. Research indicates that between 5% and 18% of wheelchair users experience wheelchair-related injuries annually, with poorly maintained wheelchairs significantly increasing injury risk. Wheelchair users who maintain their wheelchairs are substantially less likely to sustain injuries compared to those who neglect maintenance.

The Impact of Wheelchair Breakdowns

Recent community studies demonstrate that wheelchair part failure rates have tripled from 26% in 2005 to 88% in 2020 amongst community-dwelling wheelchair users. Between one-quarter and one-half of wheelchairs require repair within a six-month period, with up to one-third of these repairs resulting in adverse effects. The consequences of wheelchair breakdowns extend beyond inconvenience. Users experiencing breakdowns report being stranded at home or away from home, missing work, school, or medical appointments; and functional outcomes associated with negative health consequences including pressure injury development, rehospitalisation, pain, and depression. Repair delays compound these issues, with processes often requiring two visits and taking anywhere from two weeks to six months for completion.

Maintenance Within the WHO Service and System Framework

Service-Level Integration: The Four Steps

The WHO 2023 guidelines recommend wheelchair provision through a service model that provides, as a minimum: (1) individual assessment and selection; (2) preparation and fitting of the wheelchair for the wheelchair user; (3) information and training for wheelchair users to maximise their safe and efficient use and care of the product; and (4) follow-up to ensure the wheelchair continues to meet the user's needs. Maintenance is integrated across these four steps:

Select. During the selection step, service providers conduct comprehensive assessments that include evaluating the user's capacity and resources for ongoing wheelchair maintenance. This assessment informs decisions about appropriate wheelchair types and features that match the user's maintenance capabilities and available support systems.

Fit. The fitting step ensures the wheelchair is properly prepared and adjusted to meet the user's needs. Proper initial fit reduces unnecessary wear and tear, and service providers explain how correct fit contributes to easier maintenance and longer wheelchair lifespan.

Train. Training must be provided for wheelchair users and those who assist them to enable maximum use. This includes skills to use a wheelchair, use of wheelchair components, guiding others with whom they interact, and wheelchair maintenance and repairs. The WHO guidelines conditionally recommend training in maintenance and repairs, particularly where maintenance and repair services are not affordable, accessible, or able to provide timely services. Research demonstrates that group wheelchair maintenance training effectively improves both capacity to complete maintenance tasks and the frequency with which users perform maintenance activities.

Follow-up. 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. Follow-up has two components: review and remediation. Review involves collaboration between wheelchair users and service providers to identify how well the wheelchair continues to meet the user's needs. This includes checking the condition (i.e. state of repair) of the wheelchair, wheelchair cushion, and postural support devices; discussing any changes in the user's situation (e.g. their health, support, transportation, and environments of use); assessing fit for correct functional posture and pressure management; and confirming the wheelchair user's overall satisfaction with wheelchair performance. Remediation involves addressing and resolving any identified problems through adjustment of the wheelchair, additional training, or completing wheelchair maintenance and repairs.

System-Level Recommendations

Competent Workforce. The guidelines emphasise that wheelchair services should be provided by people with role-specific competencies. Service personnel must be trained to educate users and caregivers on routine inspection procedures, provide contact details for qualified repair professionals, and complete or arrange necessary repairs and adjustments. Different personnel may fulfill identification and referral, clinical, technical, training, and management functions, with maintenance spanning technical and training roles.

Seamless Referral and Access. Wheelchair services cannot always be fully provided close to users' communities. To ensure equitable access, service providers utilise solutions such as proactive engagement and task-shifting to networks and local providers that can assist in aspects of service delivery. Follow-up support and wheelchair repair may be managed by different providers situated closer to where people live, requiring effective referral pathways and coordination across service levels.

Systematic Evaluation. The guidelines recommend that processes to monitor, evaluate, and improve wheelchair services are in place for continuous monitoring and learning. Service evaluations should examine maintenance-related outcomes, including wheelchair breakdown rates, repair timeliness, user satisfaction with maintenance support, and the effectiveness of maintenance training. Evaluation findings inform service improvements and resource allocation decisions.

Context-Appropriate Maintenance Strategies

Resource Settings Considerations. Maintenance approaches must be adapted to local contexts. In well-resourced settings with established repair networks, user training may focus primarily on identifying problems and scheduling professional services. In less-resourced settings, users may need more comprehensive training in performing repairs themselves or accessing alternative repair options such as bicycle mechanics, welders, or local craftspeople.

Professional vs User-Performed Maintenance. Certain maintenance tasks require professional expertise, particularly those involving wheelchair alignment and tracking, spoke tensioning and wheel truing, bearing replacement, structural frame repairs, battery installation and advanced troubleshooting for powered wheelchairs, and software diagnostics and electronic systems. User-performed maintenance typically includes regular cleaning and inspection, tire pressure checks, cushion care and monitoring, tightening loose fasteners, and basic lubrication of moving parts.

Manual Wheelchair Maintenance Essentials

Inspection Components

Tires and Wheels. Properly inflated tires reduce propulsion effort and shoulder strain while extending tire and wheel lifespan. Users should check pneumatic tire pressure weekly (and more frequently in winter) by pressing firmly on the tire—if depression exceeds 5mm, inflation is needed. Solid tires require inspection for wear, cracks, and flat spots.

Cushions. Wheelchair cushions play a key role in preventing pressure injuries, yet cushion inadequacies contribute significantly to pressure injury development. Cushions require weekly inspection of covers for tears, zipper malfunctions, and worn non-skid surfaces. The cushion itself should be examined for appropriate shape, contour, and material-specific concerns. Air cushions require proper inflation and valve integrity, gel cushions need appropriate gel distribution and absence of hardening, and foam cushions must maintain intact structure without deterioration or loss of resilience. Attention to wheelchair and cushion maintenance and fit is particularly crucial in institutional settings.

Structural Components. Monthly inspections should address nuts and bolts (e.g. tightening loose fasteners without over-tightening), wheel bearings (e.g. assessing for smooth rotation and absence of noise), spokes (e.g. checking for equal tension throughout, with professional adjustment required), brakes (e.g. ensuring secure mounting and effective locking), hand-rims (e.g. confirming absence of dents, bends, or sharp edges), footrests and armrests (e.g. verifying secure attachment and proper latching), backrests (e.g. checking upholstery integrity or rigid surface condition), and frame mechanisms (e.g. ensuring proper cross-brace operation for folding frames).

Maintenance Actions

Cleaning. Monthly cleaning with warm water and mild soap protects metal and wooden parts from deterioration and prevents damage from dirt in moving parts. Particular attention should be paid to moving parts, upholstery joints, and caster axle bearings, where dirt, lint, and hair can cause premature wear.

Lubrication. Quarterly lubrication of moving parts including: folding mechanisms, caster pivots, and exposed hinges, prevents rust and reduces friction. Users should apply lubricating oil to all moving parts except sealed bearings, removing excess with a cloth.

Professional Servicing. Research demonstrates the effectiveness of regular wheelchair servicing by repair technicians in preventing wheelchair part failures and accidents. Wheelchairs should receive professional servicing at least annually, with twice-yearly servicing recommended in regions with inclement weather conditions.

Powered Wheelchair Considerations

Powered wheelchairs require additional maintenance attention due to their complexity and the potentially severe consequences of malfunction. Among reported consequences, 65% were attributed to powered wheelchair users, with wheelchairs featuring powered seat functions reporting significantly higher rates of users being stranded, injured, or missing appointments.

Key considerations include ensuring that protective shrouds remain in place and intact to prevent dirt and moisture from affecting electronics and batteries, conducting daily inspection of shrouds and motor sounds, arranging battery maintenance by qualified professionals, performing regular cleaning of powered seat function tracks, and seeking immediate professional consultation if unfamiliar noises are detected, as motor failure can leave users stranded.

Linking Maintenance to Outcomes

Injury Prevention. Tips and falls account for 65-80% of wheelchair-related injuries across all age groups. Many predictive risk factors for wheelchair-related falls and injuries are modifiable, making fall prevention education an essential component of wheelchair interventions. Proper maintenance directly addresses several modifiable risk factors, including equipment malfunction and structural integrity.

Pressure Injury Prevention. The annual incidence of pressure injuries amongst individuals with spinal cord injuries ranges between 23% and 30%, with up to 85% developing a pressure injury at some point during their lifetimes. Cushion maintenance plays a particularly crucial role in this domain. Deteriorated cushions lose their pressure-redistributing properties, significantly increasing pressure injury risk over the ischial tuberosities and other bony prominences.

Functional Participation. Studies examining wheelchair provision using comprehensive service delivery approaches demonstrate that wheelchairs provided through individualised processes of assessment, fitting, training, and follow-up result in greater satisfaction with mobility and improved quality of life. Maintenance represents an essential component of this service continuum, ensuring that benefits achieved through the Select, Fit, and Train steps persist over time through effective Follow-up.

Clinical Application for Rehabilitation Professionals

Integration Within the Four Service Steps.

Rehabilitation professionals play key roles across all four service steps, with maintenance considerations embedded throughout.

During Select. Assess the user's capacity for maintenance tasks, available support systems, and environmental factors affecting maintenance needs. Consider these factors when recommending wheelchair types and features.

During Fit. Explain how proper fit reduces wear and tear. Demonstrate correct positioning and adjustment to users and caregivers, emphasising the relationship between proper fit and ease of maintenance.

During Train. Provide comprehensive training in wheelchair maintenance appropriate to the user's context and capabilities. Training should include hands-on demonstrations and practice, visual aids and checklists for home reference, appropriate tools and resources, and information about local repair services and resources. Group training in structured formats offers a lower-cost means for centres to provide maintenance education whilst remaining effective.

During Follow-up. Conduct structured review and remediation. Assess wheelchair condition, identify problems, provide additional training as needed, and complete or arrange repairs.

Assessment Questions for Follow-up

During follow-up appointments, rehabilitation professionals should inquire about recent wheelchair breakdowns or malfunctions, frequency and type of maintenance performed, difficulties experienced with maintenance tasks, changes in wheelchair performance or user comfort, and changes in the user's situation such as their health, support, transportation, and environments of use.

Population-Specific Considerations

Different wheelchair user populations require tailored maintenance education. Individuals with tetraplegia may need caregiver-focused training, whilst paediatric users and their families require age-appropriate education. Elderly users may benefit from simplified inspection routines, and athletes and active users may need more frequent maintenance schedules.

Applying System-Level Recommendations

Competent Workforce. Rehabilitation professionals should maintain current knowledge of maintenance best practices and participate in continuing education. Collaborate with technical personnel who have specialised repair expertise, understanding respective roles and referral pathways.

Seamless Referral and Access. Establish and maintain relationships with repair providers at different service levels. Develop clear referral protocols for maintenance issues beyond the user's or therapist's scope. Ensure users understand how to access repair services in their communities.

Systematic Evaluation. Participate in service evaluation by documenting maintenance-related outcomes, contributing to quality improvement initiatives, and using evaluation data to enhance training programmes and service delivery models.

Policy and Systems Considerations

Recent legislative developments, such as Colorado's 2023 "Right to Repair" law for powered wheelchairs, aim to facilitate reduced delays by easing access to wheelchair parts and services. Such policies recognise that simple issues can mean the difference between independence and dependence. Healthcare systems should establish accessible repair networks with reasonable response times, consider coverage for preventive maintenance services, develop quality standards for maintenance providers, and create feedback mechanisms to monitor repair timeliness and effectiveness.

Conclusion

Wheelchair maintenance and care represent essential elements of the WHO's 2023 wheelchair provision framework. Effective maintenance requires collaboration between service providers with role-specific competencies, wheelchair users, caregivers, and maintenance professionals across different service levels. By embedding maintenance considerations into each service step, from initial selection through ongoing follow-up, and by strengthening systems through trained personnel, coordinated referral networks, and continuous evaluation, rehabilitation professionals can help ensure wheelchair users maintain mobility, function, independence, and health throughout their wheelchair's lifespan.

Resources

NSW State Spinal Cord Injury Service Wheelchair Maintenance Guidelines

• This document provides an outline for general maintenance that can be applied to most wheelchairs and includes a 4-Week Cycle Sample Maintenance Calendar for a Manual Wheelchair.

References