Eight Steps to Appropriate Wheelchair Provision
Original Editor - Ilona Malkauskaite as part of the Wheelchair Service Provision Content Development Project
In 2008 with input from more than twenty-five wheelchair and rehabilitation experts the World Health Organisation (WHO) released the Guidelines on the Provision of Manual Wheelchairs in Less Resourced Settings, which sought to combat the risks associated with wheelchair distribution and to address the challenges of the health sector in providing appropriate care for people with disabilities. The guidelines address manual wheelchair design, production, supply, and service delivery for long-term wheelchair users. In the Guidelines, WHO outline the following eight steps that wheelchair service personnel need to carry out to provide an appropriate wheelchair. While all elements of are key to providing a comprehensive wheelchair service, the eight steps may be carried out in a different order or steps may be combined in some wheelchair services. 
- Referral and Appointment;
- Funding and Ordering;
- Product Preparation;
- User Training;
- Maintenance, Repairs and Follow-Up.
1. Referral and Appointment
The way that wheelchair users are referred will vary. The system of referral will depend on existing services in the country. Users may refer themselves or be referred through networks made up of governmental or non-governmental health and rehabilitation workers or volunteers working at community, district or regional level. Some wheelchair services may need to identify potential users actively if they are not already receiving any social or health care services or participating in school, work or community activities.The objective of good practice in referrals and appointments is to ensure that users have equitable access to wheelchair service delivery, to increase the efficiency and productivity of the service, and to minimize waiting lists. 
Good practise in referral and appointment systems contains:
- A file establishment for user and an arranged appointment or users placement in a waiting list;
- Personnels training in wheelchair service;
- Distribution of a form for referral network agencies to complete when referring users;
- Clear guidelines for appointments priority;
- Targets setting and performance measuring;
- A screening procedure to minimize the scheduling of inappropriate referrals.
Assessment is the second step in wheelchair service. Each user needs an individual assessment, taking into account lifestyle, work, environment and physical condition. Information collected from the assessment will help the wheelchair service personnel and wheelchair user to:
- Choose the most appropriate wheelchair from those available;
- Work out what possible additional postural support may be needed;
- Decide what training or support the wheelchair user family member/caregiver may need to use and maintain their wheelchair;
- Assessment at both basic and intermediate level is carried out in two parts;
- Assessment Interview
- Physical Assessment.
Good practice in assessment:
- Assessments are carried out in a private, quiet and clean space;
- Assessments are carried out by trained personnel;
- Equipment for the assessment is readily available, including an assessment bed (plinth, mat, table), measuring tape, device for measuring angles (goniometer), foot blocks and infection control supplies;
- Assessment takes into consideration the user’s physical condition; home, school, work and other environments where the wheelchair is used; lifestyle; size and age;
- Assessments are clearly documented on an assessment form and filed for future reference;
- Where a service is unable to meet the user’s needs owing to the lack of an appropriate product or personnel with sufficient skills, the service refers the user to another service that, hosts outreach visits of more qualified personnel or documents the user’s needs to help build a picture of unmet needs to guide future service development.
Using the information from the assessment, a wheelchair prescription is developed together with the user and family members or caregivers. The prescription (selection) details the selected wheelchair type and size, special features and modifications. It also describes the training the user needs in order to use and maintain the wheelchair properly.
Good practise in prescription:
- Users are given the opportunity to see and, where possible, try samples of wheelchairs, cushions and postural support components;
- The importance of features is prioritized to help to make the most appropriate choice from what may be a limited range of available wheelchairs;
- Each wheelchair prescription is documented, either on the assessment form or on a dedicated prescription form;
- Wheelchair service personnel are given time to write up assessment and prescription notes immediately after each appointment;
- Services give users an estimate of when their wheelchair will be ready.
4. Funding and Ordering
Following prescription, it is possible to closely estimate the cost of the product being recommended. For most services, it will be essential to ensure a funding source has been identified before an order can be placed for equipment. Wherever possible, this should be in the hands of administrative rather than clinical or technical personnel. When not in stock, wheelchairs need to be ordered from an external supplier or procured from the wheelchair service workshop, which usually maintains a stock of different sizes and types of wheelchair.
Good practise in ordering:
- Keeping wheelchairs in stock can reduce waiting time;
- An order should be placed as quickly as possible to avoid delays;
- It is important to let wheelchair user to know, when a wheelchair is to be available. 
5. Product Preparation
The objective of good practice in product preparation is to prepare the wheelchair for the fitting, including modifications or custom postural support components.Trained personnel prepare the wheelchair for the initial fitting. Depending on the available product and service facilities, this may include assembly, and possible modification, of products supplied by manufacturers or manufacture of products in the service workshop. Each wheelchair being prepared is labelled with the user’s name and a serial number or bar code.The production and installation of custom seating systems or individual postural support components should be carried out by personnel with the appropriate knowledge and skills. This work should also be done in close collaboration with the assessment personnel. All mobility equipment is checked for quality and safety before the user tries it .
The following order of a wheelchair preparation:
- Check depth and width measurements of a wheelchair seat;
- Check the cushion match with the depth and width of the seat;
- Adjust: backrest height and angle,armrests height, rear wheels position, brakes position, footrests height, push handles height,
- Carry out wheelchairs safe and ready check.
The user tries the wheelchair. Final adjustments are made to ensure the wheelchair is correctly assembled and set up.
During fitting, the user and competent personnel together check that:
- the wheelchair is the correct size;
- the wheelchair is correctly adjusted for the user;
- any modifications or postural support components are fitting correctly;
- the wheelchair meets the user’s mobility and postural support needs and minimizes the risk of the user developing secondary deformities or complications.
7. User Training
The user and caregivers are trained how to use and maintain the wheelchair safely and effectively. Key areas of user training include:
- how to transfer in and out of the wheelchair;
- how to handle the wheelchair;
- basic wheelchair mobility;
- how to stay healthy in the wheelchair – for example prevention of pressure sores;
- how to look after the wheelchair and cushion and, if appropriate, dismantle and reassemble the wheelchair;
- who to contact in case of problems.
8. Maintenance, Repairs and Follow-Up
The wheelchair service provides maintenance and repair services for technical problems that can not be solved in the community. It is appropriate to carry out follow up activities at the community level as much as possible. Follow up appointments are an opportunity to check wheelchair fit and provide further training and support. The timing depends on the needs of the user and the other services that are available to them. Some users should be followed up more frequently than others. As a guide, follow-up appointments are usually made within six months of receiving a wheelchair. Basic wheelchair repair work can often be done locally at bicycle or car repair workshops.If the wheelchair is found to be no longer appropriate, a new wheelchair needs to be supplied starting again from step one.
Good practise in follow-Up:
- Whenever possible, all members of the wheelchair service team are involved in follow-up appointments. This includes clinical, technical and training personnel.
- The frequency of follow-up is determined by the individual needs of the users.
- Follow up appointments are given as a priority to users in the following categories:children (whose needs change quickly as they grow); users at risk of developing pressure sores;users who have a wheelchair with postural support modifications or additions and users (or family members/carers) who have had difficulty in following the basic training given at the service.
- Services use follow-up appointments as an opportunity to gather feedback from the user to help evaluate the quality of the service provided.
- William Armstrong, Johan Borg, Marc Krizack, Alida Lindsley, Kylie Mines, Jon Pearlman, Kim Reisinger, Sarah Sheldon. Guidelines on the Provision of Manual Wheelchairs in Less Resourced Settings. World Health Organization; Geneva: 2008. http://www.who.int/disabilities/publications/technology/wheelchairguidelines/en/ (accessed 15 June 2018).
- World Health Organization. Wheelchair Service Training Package - Basic Level. http://www.who.int/disabilities/technology/wheelchairpackage/en/ (accessed 15 June 2018).