Wheelchair Services

Original Editor - Naomi O'Reilly as part of the Wheelchair Service Provision Content Development Project

Top Contributors - Naomi O'Reilly, Stacy Schiurring, Kim Jackson, Simisola Ajeyalemi, Robin Tacchetti, Rachael Lowe, Rucha Gadgil, Amrita Patro, Jess Bell and Olajumoke Ogunleye  

Introduction

Personal mobility is essential for health, independence, and productivity. For individuals with mobility impairments, access to an appropriate wheelchair and comprehensive wheelchair services is considered a basic human right. The World Health Organization (WHO) estimates that 80 million people (or 1% of the world's population) require a wheelchair to assist their mobility, with this number set to grow as the global population ages and rates of chronic health conditions continue to increase. However, globally, between 65% and 95% of those who need wheelchairs do not have access to one. Only a well-functioning wheelchair provision system with appropriately trained personnel can guarantee optimal personal mobility. Barriers to wheelchair provision, such as wait times, funding constraints, and inadequate service infrastructure, occur throughout the provision timeline and significantly impact users' rights, independence, and personal freedom.

In May 2023, the WHO released updated Wheelchair Provision Guidelines in collaboration with the International Society of Prosthetics and Orthotics (ISPO) and the International Society of Wheelchair Providers (ISWP). These guidelines state that appropriate wheelchair provision must be delivered through wheelchair services rather than merely focusing on wheelchair delivery. The guidelines emphasise that the best outcomes in wheelchair access occur when wheelchair users benefit from wheelchair selection following an individual process of assessment, fitting, training, and follow-up, provided by appropriately trained personnel. This requires effective wheelchair provision systems integrated within health and other sectors, supported by clear policies, adequate product availability, and skilled personnel.

The Global Challenge

Historically, wheelchair service delivery has not been an integral part of rehabilitation services in many contexts. This gap exists due to numerous factors, including poor awareness, scarce resources, a lack of appropriate products, and insufficient training for health and rehabilitation personnel in wheelchair service delivery. The problem is particularly acute in low- and middle-income countries, where the majority of people requiring wheelchairs reside and where unmet need is highest.

In many countries, users depend on charity or external donations. Donated wheelchairs are often inappropriate and of poor quality, creating long-term problems for both the user and the healthcare system. Users receiving charity wheelchairs are not in a position to demand quality or appropriate fit. Research in India revealed that 60% of wheelchair users who received donated wheelchairs stopped using them due to discomfort and unsuitability for their environment. The result is that many people requiring wheelchairs either do not receive one at all, or receive one without proper assessment, prescription, fitting, and follow-up. Many users, including people with spinal cord injury, receive wheelchairs without appropriate cushions or basic instructions, which can lead to pressure injuries and secondary complications. Hospital-acquired pressure ulcers cost the US health system $26.8 billion annually, with over 50% of the cost attributed to treating Stage 3 and 4 pressure injuries, highlighting the significant clinical and economic consequences of inadequate wheelchair provision.

There is, however, increasing global awareness of the importance of providing individual assessment, fitting, and training in wheelchair use. In numerous settings, wheelchair services have been established using different models of service delivery, including centre-based services, community-based services, outreach services, and integrated rehabilitation programmes. Where user groups are well informed and service providers have the necessary knowledge and support, wheelchair services are becoming integrated into existing rehabilitation activities.

The WHO Wheelchair Provision Framework

The 2023 WHO guidelines describe four key service delivery steps, consolidating from the eight steps presented in the 2008 guidelines to ensure greater relevance across all settings. The four steps are:

1. Select (Assessment and Selection): Wheelchairs must be provided using a process of individual assessment and selection. This involves the wheelchair user, in collaboration with appropriately trained personnel, defining their physical, functional, environmental, and lifestyle needs and preferences, then selecting the wheelchair and features that best meet those needs. WHO defines the complexity of wheelchair users' mobility and postural support needs as basic, intermediate, and advanced. This classification helps structure services and determine appropriate staffing levels and referral pathways.

2. Fit (Preparation and Fitting): Wheelchairs must be prepared and fitted for each person based on their individual assessment. This includes making necessary adjustments, modifications, and providing appropriate pressure management solutions such as cushions. Proper fitting is essential to prevent secondary complications including pressure injuries, postural deformities, and pain.

3. Train (User Training and Education): User training is a critical component of wheelchair service delivery. There is moderate quality evidence that structured wheelchair skills training increases wheelchair skills capacity scores by 14.0% post-training compared to controls, representing a 21.2% relative increase over baseline, with training being particularly effective for new wheelchair users. Training should address wheelchair propulsion, manoeuvring skills, transfers, maintenance, and pressure injury prevention. Recent evidence demonstrates that manual wheelchair training is delivered across diverse contexts and is commonly directed towards wheelchair users with spinal cord injury, with intended training outcomes most frequently mapping to activity and participation.

4. Follow-up (Ongoing Support and Maintenance): 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 includes reassessment, repairs, modifications as needs change, and continued support. Telehealth offers one potential solution to improve access to follow-up services, particularly for users in rural settings or areas with limited access to specialised wheelchair services.

Models of Wheelchair Service Delivery

Effective wheelchair service delivery requires careful planning and management of resources, as well as adequate education and training for all personnel involved in wheelchair provision. Different models of service delivery can be employed depending on local context, resources, and identified needs.

For a more in-depth information please read this optional Physiopedia Page on the Multidisciplinary Team in Wheelchair Service Provision.

Wheelchair Service Centres. These operate from dedicated facilities with clinical assessment areas, user education spaces, and technical workshop capacity. They may share infrastructure with existing healthcare or rehabilitation facilities. Wheelchair service centres employ trained specialist personnel to address diverse user requirements and provide comprehensive wheelchair provision to all user groups. These centres play a crucial role in community engagement, establishing networks with local wheelchair providers and referral pathways, delivering training and clinical supervision to community-level services, educating referral sources about appropriate wheelchair provision, and facilitating connections with education, employment, and other community development initiatives.

Community-Based Wheelchair Services. These function primarily within community settings, utilising shared facilities alongside other primary healthcare and rehabilitation programmes. Services are delivered by community health workers and rehabilitation personnel trained in fundamental wheelchair provision, with ongoing supervision from wheelchair service centre staff. Community-based services typically supply basic manual wheelchairs to users without requirements for individualised modifications or specialised postural support. They identify users with complex seating and mobility needs for referral to specialist centres and, where capacity exists, provide ongoing community-based support for maintenance, repairs, and follow-up care. These services may also address environmental accessibility needs, including home modifications such as doorway widening and ramp installation.

Table 1.o: Integrated wheelchair service delivery approach, based on the 2023 WHO Wheelchair Provision Guidelines four-step framework.

Service Level	Structure and Resources	Primary Roles and Functions	User Populations Served
Wheelchair Service Centre	Operates from a dedicated facility with: Clinical assessment areas for evaluation and prescription User education and training spaces Technical workshop capacity for modifications and repairs May share infrastructure with existing healthcare or rehabilitation facilities Employs specialist wheelchair service personnel including: Rehabilitation professionals (physiotherapists, occupational therapists) Wheelchair technicians Seating and mobility specialists	Assessment and Selection (Step 1): Conducts comprehensive assessments across all complexity levels (basic, intermediate, advanced) Individual selection of wheelchairs based on physical, functional, environmental, and lifestyle needs Preparation and Fitting (Step 2): Prepares and fits wheelchairs for individual users Provides complex modifications and postural support solutions Prescribes appropriate pressure management systems Training (Step 3): Delivers evidence-based wheelchair skills training Provides education on maintenance and pressure injury prevention Trains caregivers when appropriate Follow-up (Step 4): Provides ongoing reassessment and support Manages repairs and modifications System Support Functions: Establishes referral networks and pathways Delivers training and clinical supervision to community-based services Educates referral sources about appropriate wheelchair provision Facilitates connections with education, employment, and community services Coordinates outreach services and telehealth provision	All user groups: Users with basic mobility and postural support needs Users with intermediate complexity needs Users with advanced/complex needs requiring: individualised modifications, specialised postural support, complex pressure management, and multiple comorbidities Special populations: Paediatric users Users with progressive conditions Users requiring powered mobility Users with cognitive impairments requiring caregiver training
Community-Based Wheelchair Services	Functions within community settings using: Shared facilities alongside primary healthcare and rehabilitation programmes Basic clinic space for assessment Limited training areas Basic workshop capacity for minor adjustmentsDelivered by: Community health workers Community-based rehabilitation personnel Rehabilitation assistants Trained in fundamental wheelchair provision with ongoing supervision from wheelchair service centre staff	Assessment and Selection (Step 1): Conducts assessments for users with basic mobility and postural support needs Identifies and refers users with intermediate or advanced complexity needs to wheelchair service centres Preparation and Fitting (Step 2): Fits basic manual wheelchairs without complex modifications Makes minor adjustments within scope of training Training (Step 3): Provides basic wheelchair skills training Educates on basic maintenance and care Delivers pressure injury prevention education Follow-up (Step 4): Provides ongoing community-based support Manages basic maintenance and minor repairs Coordinates referrals for reassessment when needs change Environmental Support: Addresses environmental accessibility needs Facilitates home modifications (doorway widening, ramps) Connects users with local resources and support services	Primary focus: Users with basic mobility and postural support needs who can sit upright without additional postural support Users requiring basic manual wheelchairs without individualised modifications Users living in rural or remote areas Referral to specialist centres: Users with intermediate or advanced complexity needs Users requiring specialised seating or modifications Users with rapidly changing needs Users at high risk of secondary complications
Linkages and Coordination	Referral pathways: Clearly defined criteria for referral between community and specialist services Established communication protocols Documented referral processes Technology integration: Telehealth for remote consultations and follow-up Digital platforms for service coordination Electronic health records (where available) Outreach models: Mobile clinics for remote areas Periodic specialist visits to community sites Hybrid service delivery combining in-person and telehealth	Seamless service coordination: Timely referrals based on complexity classification Shared care planning between service levels Continuity of follow-up support Clear documentation and communication Task-shifting: Community personnel provide ongoing support for users initially assessed at wheelchair service centres Local providers manage maintenance and repairs closer to users' homes Peer support networks facilitate user education Quality assurance: Regular supervision and mentoring from specialist services Ongoing professional development for community personnel Monitoring and evaluation of service outcomes User feedback mechanisms	All wheelchair users benefit from: Appropriate service level matching user needs Reduced travel burden through community-based follow-up Timely access to specialist services when needed Continuous support throughout wheelchair lifespan Coordinated care across service levels

Utilising Existing Personnel and Resources

It is not necessary to create a new profession to provide wheelchair services. With additional training, many health and rehabilitation personnel can take on the duties required for wheelchair service delivery. Community health care workers, community-based rehabilitation workers, nurses, physiotherapists, occupational therapists, orthotists, and prosthetists can all be trained to fulfil clinical roles in wheelchair services. Similarly, skilled craftspeople, mechanics, and orthotic and prosthetic technicians can fulfil technical roles with appropriate training. The International Society of Wheelchair Professionals has developed assessment tools to test wheelchair service personnel knowledge and support good practice, with recent evidence demonstrating that years of experience significantly contributes to competency.

Wheelchair services can also make use of the skills, technologies, and capacities of local industries. For example, bicycle repair shops can repair wheelchairs, and tubular furniture makers possess basic skills and knowledge applicable to wheelchair construction and modification. This integration of local resources enhances sustainability and accessibility of wheelchair services.

Integration with Existing Services

A wheelchair service centre or department can be established within existing rehabilitation services. Such services already have users accessing care for health or rehabilitation needs and possess much of the required infrastructure. Examples of rehabilitation services well suited to the integration of wheelchair services include prosthetics and orthotics services, spinal injury centres, and community-based rehabilitation programmes. Wheelchair services cannot always be fully provided close to users' communities; therefore, to ensure equitable access, service providers often need to utilise solutions such as proactive engagement and task-shifting to networks and local providers that can assist in aspects of service delivery. Outreach models and telehealth can bridge distance gaps, particularly for follow-up support and wheelchair repairs managed by providers situated closer to where people live.

Stakeholders and Resources

Stakeholders directly involved in planning, implementation, and participation in wheelchair service delivery include users and their families or caregivers; government authorities including ministries responsible for health, social welfare, and education; existing health and rehabilitation services managed by governmental, private, nongovernmental, or disabled people's organisations; supporting organisations providing technical input or funding; rehabilitation personnel and their professional organisations; and wheelchair service personnel.

Essential resources required to implement wheelchair services include a reliable supply of wheelchairs that meet agreed standards; access to different types and sizes of wheelchairs to meet the varied needs of individual users; personnel with training in wheelchair service delivery; clinical facilities providing sufficient space for assessment, user training, and wheelchair storage; workshop facilities for wheelchair modifications and postural support provision; materials for wheelchair modifications and custom components; and sustainable funding to support both products and services.

System-Level Considerations

The 2023 WHO guidelines include system-level recommendations emphasising the need for trained personnel fulfilling different roles, integrated and seamless referral processes, and systematic evaluation of wheelchair provision. Effective wheelchair services require the support of interrelated components within the WHO-GATE 5P framework (WHO Global Cooperation on Assistive Technology): policy, products, provision, personnel, and place. Government and ministries play a leadership role in formulating policies and coordinating different sectors to ensure policies are fit for purpose, with parallel processes to enforce implementation and secure funding.

Recent evidence from the UK National Health Service highlights persistent challenges including inadequate data systems for tracking wheelchairs, supply chain management issues, and the need for value-based procurement that considers long-term effectiveness rather than just initial purchase price. Addressing these systemic issues requires coordinated efforts across multiple stakeholders and integration of wheelchair services into broader health and rehabilitation systems.

Conclusion

Wheelchair provision is fundamentally about enabling people with disabilities to become mobile, remain healthy, and participate fully in community life. Wheelchair services provide the essential framework for assessing individual user needs, selecting appropriate wheelchairs, training users and caregivers, and providing ongoing support and referral to other services where appropriate. Recent evidence emphasises that training programmes grounded in educational theory offer a systematic framework to facilitate learning and outcomes, though most current training focuses on knowledge and skills acquisition rather than broader participatory outcomes. As rehabilitation professionals, understanding the principles of evidence-based wheelchair service delivery and advocating for comprehensive wheelchair services is essential to optimising outcomes for wheelchair users globally.

Resources

Optional Additional Reading

• 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.
• Layton N, Spann A, Khan M, Contepomi S, Hoogerwerf EJ, Bell D, de Witte L. Guidelines for assistive technology service provision–A scoping review. Disability and Rehabilitation: Assistive Technology. 2024 Nov 16;19(8):2806-17.
• World Health Organization. Wheelchair provision guidelines. World Health Organization; 2023 Jun 2.
• Wheelchair Referral and Appointments
• Wheelchair Funding and Ordering

Wheelchair Services Innovations

References