WHEELCHAIR

Manual
SEATING &
Wheelchair Guide
POSITIONING
GUIDEintroduction to optimizing
A comprehensive
manual mobility for client function
Manual Wheelchair Guide

Purpose of this Guide

One of the greatest barriers to the provision of seating and wheeled mobility
is first identifying the need and then documenting and justifying that need
for equipment. This guide is meant to be a helpful resource to healthcare
professionals to:

• Identify the need for manual mobility

• Translate the need for a mobility device to the
most appropriate wheelchair model and options
• Understand how to effectively document and
justify the equipment chosen and meet the
necessary requirements
• Understand what the components of an ultra
lightweight manual wheelchair are and how to
appropriately measure for optimal configuration

Look for these info boxes throughout the guide.

They include quick tips or takeaways for that section.

This guide was created using process and funding guidelines for the United
States including Medicare coding terminology. Therefore, some terms such
as K0005 and Ultra Lightweight Manual Wheelchair, are considered to be
interchangeable throughout.

This guide is meant to be a comprehensive introduction to manual mobility.

For advanced learning opportunities, visit the education tab at permobilus.com

Note This guide is not intended to replace the advice of a medical professional.

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 Introduction

Table of Contents
GETTING STARTED Manual Wheelchair Universal Terms 1
Common Challenges 2
THE PROCESS Identifying the Need 3
Qualifying for a Manual Wheelchair 4
Manual Wheelchair Justification 5-6
DME VS CRT EQUIPMENT Understanding DME & CRT Equipment 7
DME 8 - 10
CRT 11 - 14
Manual Wheelchair Comparison Chart 15 - 16
DME, Short-Term Use Wheelchairs 17 - 18
CRT, Full-Time Use Wheelchairs 19 - 20
CRT Ultra Lightweight Manual Wheelchairs 21 - 22
Tips for Justifying a K0005 MWC 23 - 24
K0005 CONFIGURATION K0005 Ultra lightweight MWC Configuration 25
Measuring for a K0005 Wheelchair 26
Seat-to-floor height 27 - 28
Seat slope 29 - 30
Ergo seat 31 - 32
Foot support-to-seat length 33
Front frame angle 34
Seat width 35
Front seat width 36
Footrest width 37
Seat sling depth 38
Frame depth 39
Seat back height 40
Seat-to-back angle 41
Position of the rear wheel axle 42
Horizontal axle positioning 43 - 44
Vertical axle positioning 45
MWC propulsion 46
Propulsion patterns 47
Propulsion efficiency 48
Rear wheel options 49
Rear wheel camber 50
Caster options 51 - 52
Additional K0005 Ultra Lightweight MWC options 53
MWC POWER ASSIST Power Assist 54
Hub-Mounted Power Assist 55
Rear-Mounted Power Assist 56
CONCLUSION 57
QUICK GUIDE - MWC FIT 58 - 62
GLOSSARY 63
REFERENCES 64

Manual Wheelchair Guide 5

Manual Started
Getting Wheelchair Guide

Manual Wheelchair
Universal Terms

Canes

Back Handgrip
upholstery

Arm rest

Side panel

Rear wheel
Seat
upholstery Handrim /
pushrim

Front
hanger

Axle

Wheel lock
Foot plate

Front fork

Caster
wheel

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 Getting Started

Common Challenges

Lack of experience
identifying the need for
wheeled mobility
Lack of
experience with Lack of formal
documentation education on
requirements wheeled mobility

CHALLENGES TO Fear of
Time PROVIDING THE increased
paperwork
constraints APPROPRIATE
WHEELCHAIR
Fear of
getting it
wrong
Lack of
understanding of
funding sources
Unfamiliarity with the types
of wheelchairs available

Despite wanting what is best for our clients, the above

factors may prevent us from doing it.

Manual Wheelchair Guide 2

Manual
The Process
Wheelchair Guide

Identifying the Need

HOW DO I KNOW IF MY PATIENT NEEDS
A WHEELCHAIR?

Consider your patient’s quality of life. Document

any of the indicators below to justify the need.
1. Patient is non-ambulatory
2. Demonstrates decreased safety with ambulation or is at risk for falls within the
home. Ask about history of falls; perform an objective balance assessment, e.g.
BERG Balance Scale (BBS), Dynamic Gait Index (DGI), Timed Up and Go (TUG)
3. Requires assistance for ambulation within the home and wheeled mobility
would allow independence
4. Requires increased time for ambulation within the home. Perform a gait speed
test; think about performing ADLs in a reasonable amount of time
5. Unable to consistently ambulate throughout the day in the home, which
affects their ADLs. Look at a 24-hour period
6. Their current wheelchair is in disrepair or not meeting their needs for mobility
or postural support.

Here are scenarios where wheeled mobility could

significantly increase a person’s quality of life:
• They can ambulate but are at high risk of falls
• They have frequent urge incontinence because they are unable to get
to the restroom on time
• Their O2 saturations drop below or heart rate increases above a safe
range with ambulation
• Their day consists of sitting in a recliner and transferring to a bedside
commode as needed
• Nature of their diagnosis, over-fatigue is contra-indicated, and a WC is
required in order to avoid exacerbation of symptoms.

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 The Process

Qualifying for a
Manual Wheelchair
NOW THAT I KNOW MY CLIENT WILL BENEFIT
FROM A WHEELCHAIR, WHAT DO I DO?

Wheelchair selection is not diagnosis specific and

requires evidence of medical necessity. Step one is
a physician's visit with notes that state:

• Mobility related diagnosis - e.g. hemiplegia due to stroke

• Symptoms that affect mobility
• Mobility Related ADLs (MRADLs) affected by the mobility limitation
• Current ambulation limitations. Why they cannot ambulate at a safe,
functional level

Then, a referral is made to PT/OT and the fun begins! It becomes

our task to evaluate the client and determine what level of
wheeled mobility they need to lead safe, functional lives.

The documentation must match from MD to PT/OT!

If the MD says they can ambulate or if a diagnosis code
does not match, it will be a problem.

Manual Wheelchair Guide 4

Manual
The Process
Wheelchair Guide

Manual Wheelchair
Justification
HOW DO I JUSTIFY MY CLIENT'S
NEED FOR A WHEELCHAIR?

Prior to choosing the type of wheelchair, the PT/OT

needs to justify the need for a manual wheelchair.

Ask yourself the following questions, and the answers

will begin to guide you towards the right wheelchair:

1. Does your client have a mobility limitation that significantly impairs his/
her ability to participate in one or more MRADLs in the home?
Does it prevent them from doing MRADLs?
Are they unsafe to perform MRADLs?
Can they perform MRADLs in a reasonable time frame?
2. Can the mobility limitation be resolved by a cane or walker?
3. Do they have the desire or capability to propel a wheelchair?
If they can’t propel, do they have a willing caregiver?
4. Does the client’s home have the space/layout for functional wheelchair use?
Measure doorways and ask your ATP for required measurements to
get through doorways based on the wheelchair model selected
Measure the time it takes to propel the WC to the bathroom from
someplace else in the home

Always document how the right equipment allows them

to perform routine tasks more independently.

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 The Process

WHAT IF YOUR CLIENT ALREADY

USES A WHEELCHAIR?

Keep in mind the 5-year lifetime rule. Many insurers will

not pay for new equipment unless the current equipment
is more than 5 years old or there has been a significant
change in medical condition.

If your client uses a wheelchair already, ask the following:

1. How is their posture in their wheelchair?

2. Do they have pain when using their wheelchair?
3. Can they effectively propel their wheelchair?
4. Are they independent in their ADLs?
5. How old is their wheelchair?
6. Was it originally ordered for them, or did they get it from someone else?
7. Consider this: most of us are unaware that a K0004 or lower wheelchair
can be a rental. Investigate to find out, is their wheelchair being rented?
If so, has it been rented for less than a year? If it has been rented for
less than a year, keep in mind that it could be replaced with a different
one. More information on page 24.

Just because a person already has a wheelchair, it

doesn’t mean it’s the most appropriate one for them!

Manual Wheelchair Guide 6

Manual
DME vs CRT
Wheelchair
Equipment
Guide

Understanding DME
& CRT Equipment
MY CLIENT HAS THE NEED, BUT HOW DO
I GO ABOUT RECOMMENDING THE RIGHT
EQUIPMENT FOR THEM?

Let's start with the basics. When it comes to

seating and wheeled mobility, products are
divided into two groups:

Durable Medical Equipment (DME) and

Complex Rehabilitation Technology (CRT).

Clients will qualify for certain equipment based on the severity

or complexity of their condition. Coverage criteria for CRT MWCs
is based on function. Lesser products must have been tried and
ruled out in documentation.

"CRT products include medically necessary and individually configured

manual and power wheelchairs, seating and positioning systems, and
other adaptive equipment such as standing devices and gait trainers. This
specialized equipment requires evaluation, configuration, fitting, adjustment,
or programming to meet the individual’s medical needs and maximize
function and independence.

CRT products must be provided by individuals who are certified, registered

or otherwise credentialed by recognized organizations in the field of CRT and
who are employed by a business specifically accredited by a CMS deemed
accreditation organization to provide CRT."

“National Coalition for Assistive and Rehab Technology.” NCART, 2019, www.ncart.us/.

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 DME vs CRT Equipment

DME
DME equipment must meet the following criteria:
• Used for a medical purpose
• Used in the home
• Able to withstand repeated use
• Not usually useful to someone who is not sick, injured, or disabled

WHO MIGHT BE AN APPROPRIATE USER FOR

DME MOBILITY EQUIPMENT?

The list below can help you identify if your client's

mobility needs might be met by a DME wheelchair:

• Short-term mobility needs (e.g. • Does not have a postural deformity

temporary limitations post-surgery, and is at minimal to no risk for
fracture, or other medical condition) developing one
• Sits in the wheelchair for short periods • Sits in "standard" dimensions
of time (e.g. for transport pushed by without compromise
someone else) • Has normal tone or minimal tonal
• Propels only short distances abnormalities
• Has limited/no need for positioning • Has good sitting balance
support or adjustment beyond that • Does not have pain with sitting
provided by an appropriate seat
• Has a non-progressive condition
cushion or back support

Medicare requirements for DME equipment:

• Physician order and recent exam documenting need for mobility device
• No PT/OT evaluation or ATP involvement is required
• Specific justification of the product may come from physician or therapist
• On-site home evaluation is not required (but you should always conduct one if you
are involved)

Manual Wheelchair Guide 8

Manual
DME vs CRT
Wheelchair
Equipment
Guide

DOES THAT MEAN THAT TYPICALLY CLIENTS

WITHOUT A SERIOUS INJURY OR CONDITION
SHOULD ONLY NEED DME EQUIPMENT?
Definitely not. Go back over the list of qualities that a
DME wheelchair user should have. With your client in
mind, if you answer "no" or "not really" to ANY of those
traits, they may benefit from more advanced equipment.

The populations below (but not limited to) have traditionally been provided
with standard DME equipment. This does not mean that it is actually
appropriate for them.
• Elderly clients • Someone with a low activity level
• Bariatric individuals • Clients dependent in mobility

Always consider best clinical practice when dealing with ANY population and
fight to provide what is most clinically appropriate. Many of these and other
individuals might actually benefit from:
• A lighter weight and optimally configured wheelchair to increase and/or allow their
ability to propel and independently perform ADLs
• Adjustability in their seating system to help maintain posture, prevent deformities, and
decrease pain
• Individualized sizing to increase function, mobility, skin protection, and sitting
tolerance

An appropriate wheelchair that is configured, adjusted, and uniquely fit to

them can increase independence, activity level, and quality of life for more
than just the individual who is already active and independent.

Remember the 5-year rule and consider their prognosis

to ensure you are meeting their needs over time.

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 DME vs CRT Equipment

The Process of Getting a

DME Manual Wheelchair
Client is a non-ambulator or a Request an order from
non-functional ambulator. the physician.

Based on condition and Contact the DME company to

prognosis, the client will have the wheelchair delivered.
benefit from a wheelchair Remember a cushion should be
for short-term use. used with ANY wheelchair.

WHAT IF MY CLIENT ALREADY HAS A

STANDARD DME MANUAL WHEELCHAIR?

You are not limited to the type of wheelchair that your

client has used in the past if they could benefit from
better equipment.

People, circumstances, legislation, and technology all change over time. If

your client already has a wheelchair, it does not automatically mean that it is
the most appropriate choice for them now or that it necessarily ever was.

You also have the option to provide ANY type of seating and positioning
equipment, even CRT products, for a DME wheelchair if it benefits your client.

It is up to you to advocate for your clients. Perform your evaluations to

help justify the proper equipment choices to address your clients' needs now
and over time as best you can.

Just because a model of wheelchair was used historically

by your client, it doesn’t mean their new equipment
should be limited to the same technology.

Manual Wheelchair Guide 10

Manual
DME vs CRT
Wheelchair
Equipment
Guide

CRT
CRT products are significantly different from standard DME. The description
below will help define the difference in products that qualify as CRT:
• Medically necessary, individually-configured manual and power wheelchairs,
adaptive seating systems, alternative positioning systems, and other mobility devices
• Require evaluation, fitting, configuration, adjustment, or programming
• Designed to meet specific and unique medical, physical, and functional needs of
individuals to optimize independence and function.

A primary diagnosis resulting from a congenital disorder, progressive or

degenerative neuromuscular disease, or from certain types of injury or
trauma may be a place to start thinking CRT, but do not limit yourself to
those diagnoses.

WHO MIGHT BE AN APPROPRIATE USER

FOR CRT MOBILITY EQUIPMENT?

A seating evaluation will define if there is need for CRT

equipment, but the list below can help you identify the
type of user appropriate for CRT equipment.

• Uses a wheelchair as primary mobility • Needs specific support, configuration,

every day and/or adjustments to maintain
• Sits in the wheelchair for long periods posture, protect skin, and maximize
of time function

• Has limitations in sitting balance • Propels on varied surfaces/terrain

indoors and outdoors
• Needs specific dimensions to maintain
posture and optimize function • Has tonal abnormalities that interfere
with positioning/mobility
• At risk for/has current postural
deformities • Has a progressive condition

• Has pain in sitting

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 DME vs CRT Equipment

Requirements for the provision of CRT equipment:

• MD* has a face-to-face exam and documents the need for a mobility device
• MD* writes order for MWC, PMD, and/or wheelchair seating
• MD* writes referral for wheelchair evaluation or signs PT/OT POC
• OT/PT performs clinical evaluation
• ATP performs technology assessment and equipment trials with PT/OT
• PT/OT writes clinical documentation
• Physician* signs PT/OT documentation
• Supplier/ATP submits paperwork to insurance
• ATP and/or PT/OT deliver, fit, and provide training for equipment
*Could also be a NP, PA, or CNS

Providing CRT equipment:

• Requires more knowledgeable, skilled, and experienced
professionals
• Requires specialized evaluations, measurements, trials,
fittings, training, education, and ongoing modifications
• CRT companies must comply with more rigorous quality
standards under Medicare

Knowing whether your client will be a short-term/part-

time or long-term/full-time wheelchair user, will help you
identify whether they will require DME or CRT equipment.

A CRT wheelchair is going to be best practice for a full-time

wheelchair user every time!

Manual Wheelchair Guide 12

Manual
DME vs CRT
Wheelchair
Equipment
Guide

The Process of Getting a

CRT Manual Wheelchair
WHERE DO WE START?

Let's look at the big picture of

how to get CRT equipment:

Nurse/PT/OT identify
the need for a wheelchair

Physician/PA/NP:
Outpatient face-to-face appointment No need determined.
OR Inpatient assesses for need Doesn't qualify.

Yes, there is need.

PT/OT eval to assess physical, postural,

and functional issues/limitations related
to patient's ability to perform mobility
related ADLs (MRADLs) safely and within Doesn't qualify for
a reasonable amount of time equipment.

Yes, qualifies for

equipment.

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 DME vs CRT Equipment

PT/OT contacts ATP/Dealer to

discuss what patient qualifies for Doesn't qualify
and options for equipment for equipment.

Yes, qualifies for

equipment.

ATP/Dealer meets patient with OT/PT

for evaluation, trial and comparison
of equipment to select the most
appropriate products.

PT/OT completes Letter of

Medical Necessity (LMN)

LMN sent to physician for

signature/approval

LMN submitted and

approved by insurance

Fitting with OT/PT/ATP/Dealer in

outpatient clinic or home

Follow up with patient in 4-6

weeks for outcomes

This guide will help you more easily identify

the most appropriate mobility device.

Manual Wheelchair Guide 14

Manual
DME vs CRT
Wheelchair
Equipment
Guide

Manual Wheelchair
Comparison Chart

Standard
Standard
Hemi Height

Equipment Category: DME DME

Medicare Code: K0001 K0002

Meant for long-term sitting? No No

Dimensions:

Wheelchair weight without legrests >35 lbs >35 lbs

Seat width: standard 16", 18", 20" 16", 18", 20"

Seat depth: standard 16" 16"

Weight capacity 300 lbs 300 lbs

Back height 18" 18"

Lowest achievable seat-to-floor height 21" 19"

Adjustability to accommodate for postural abnormality:

Arm rest height No No

Back height No No

Seat-to-back angle No No

Ability to create a fixed tilt No No

Seat-to-floor height (STFH) No Hemi height only

Legrest options:

Standard, elevating (ELR), & swing-away Yes Yes

Heavy duty wheelchairs
DME K0006-K0007
Same structure and features as
K0001-K0003 MWCs, but reinforced
for greater weight capacity.

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 DME vs CRT Equipment

High-Strength Ultra
Lightweight Tilt-in-Space
Lightweight Lightweight

DME DME CRT CRT

K0003 K0004 E1161 K0005

Only w/ appropriate
No Yes Yes
configuration

33 - 35 lbs 30 - 34 lbs >45 lbs <30 lbs

16", 18", 20" 16", 18", 20", 22" 16", 18", 20" Customizable

16", 18" 16", 18", 20" 16", 18", 20" Customizable

300 lbs 300 lbs 300 lbs Customizable

18" 16" to 20" 24" Customizable

17" 13.5" (most 14.5") 17" Customizable

No Yes Yes Yes

No Yes Yes Yes

No Yes Yes Yes

No Yes Yes Yes

Yes Yes 17" - 21" Yes

Yes Yes Yes Yes + more

This chart is for reference purposes only.

Note
Wheelchair features vary according to manufacturer and model.

Manual Wheelchair Guide 16

Manual
DME vs CRT
Wheelchair
Equipment
Guide

DME, Short-Term
Use Wheelchairs
Short-term (and/or part-time) means that the client will only need a wheelchair
for a period of time, temporarily during recovery from surgery or mild to
moderate injury, and they are not at risk for postural issues or pain. They
might use the wheelchair for short periods of time throughout the day and/or
for longer distances to reduce fatigue.

Standard MWCs: (K0001, K0002, K0003)

Standard Heavy Duty MWCs: (K0006, K0007)
These wheelchairs are most
appropriate for use on firm, level
surfaces and are not appropriate
for full-time/long-term use.

Considerations Why it matters

Cannot be optimally configured to an individual
Minimal adjustability if any which can result in decreased comfort, inefficient
propulsion, and poor postural support
Solid tires are not designed for uneven terrain,
Front casters and tires are
carpet, or sloped surfaces and can increase
usually solid tires
difficulty of propulsion
Weight is distributed to the front caster, making
Rear wheel position is fixed the wheelchair harder to push. This wheel position
and rearward results in an inefficient push stroke, leading to
fatigue and risk of shoulder injury over time
This makes ANY self-propulsion inefficient and
Heavy
puts the user at risk for fatigue and injury
Inappropriate arm rest height can interfere with
Arm rest height is not propulsion and can affect the overall seated
adjustable posture. This can also increase the risk of
postural deformity over time
Minimal seat-to-floor height
STFH affects foot propulsion
(STFH) adjustment if any

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 DME vs CRT Equipment

Manual Recline WCs: (E1225/E1226):

These wheelchairs are similar in features
to standard WCs, but provide the option of
changing the seat-to-back angle. The back
support has an extension that supports the
head posteriorly when reclined.

Considerations Why it matters

Heavier due to hardware, back height, Makes it more difficult to self-propel
elevating legrests, anti-tip bars and transport
Same consideration as Standard MWCs (previous page)

E1225 = semi-reclining (15° & 80°), E1226 = fully-reclining (80° or greater)

High Strength Lightweight MWCs: (K0004)

A K0004 is similar to a standard wheelchair, but
is designed to be somewhat lighter and more
adjustable. They are not intended for full-time/
long-term use, but for part-time or intermittent
use on firm, level surfaces. They may be partially
disassembled by caregivers for transport.

Considerations Why it matters

This can improve self-propulsion
Some have partial rear seat-to-floor
efficiency and/or create a "fixed dump"
height adjustability
or seat slope for positioning
This can allow for better foot
Have lower achievable STFH of 14.5"
propulsion for average lower leg length
compared to Standard MWCs
individuals
This allows for changing the seat-to-
Some have back cane adjustability
back angle (STBA)
Some have arm rest height This allows for improved rear wheel
adjustability access and postural support

ALWAYS verify K0004 features before ordering. Not ALL K0004 MWC models have adjustability

Manual Wheelchair Guide 18

Manual
DME vs CRT
Wheelchair
Equipment
Guide

CRT, Long-Term
Use Wheelchairs

Long-term (and/or full-time) means that the client will need a wheelchair indefinitely
as their primary means of mobility whether independent or dependent.

Manual Tilt-in-Space for a dependent wheelchair user

When is a Tilt-in-Space wheelchair appropriate?

• Client is dependent in mobility
• Client is unable to perform independent pressure relief
• Client requires gravity-assisted positioning/repositioning
• Client requires postural support, head and trunk control, and accommodation of
postural asymmetries
• The goal is to increase sitting tolerance/endurance
• Client needs improved line of sight due to forward head posture
• Client will benefit from trunk support and open thoracic posture for increased
respiratory function
• Client requires safe positioning for feeding/gravity-assisted swallowing

A manual tilt-in-space wheelchair requires a PT/OT

evaluation, justification that other manual wheelchairs
are not appropriate, and an ATP involved in the process.

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 DME vs CRT Equipment

Refer back to page 11 and the list of appropriate users & list of potential risks to a
wheelchair user that a CRT MWC can address.

K0005 Ultra lightweight MWC for an independent user

This is THE manual wheelchair for a full-time wheelchair user with goals to be
active at home and in the community. These wheelchairs can be individually
configured to meet the needs of the wheelchair user and optimize function
and propulsion. They are designed to be used on indoor and outdoor
surfaces in the community and can be folding or rigid.

A K0005 wheelchair is the BEST PRACTICE for any full-time

wheelchair user!! The K0004 is never "good enough."

Manual Wheelchair Guide 20

Manual
DME vs CRT
Wheelchair
Equipment
Guide

CRT Ultra Lightweight

Manual Wheelchairs
Requirements:
• Client is a full-time/long-term
wheelchair user
• Client requires customization Seat width
such as axle configuration, wheel
camber angle, front and/or rear
seat-to-floor height (seat slope),
or WC frame size that can’t be
accommodated by a K0001-K0004
• This requires an evaluation by a
PT/OT, a letter of medical necessity,
and the involvement of an ATP in
the equipment selection process

Wheel camber

Seat slope

Axle
adjustment

Front frame angle

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 DME vs CRT Equipment

Rigid vs folding frame

one-piece
Cross bars
frame
connect Removable
Integrated frame leg rests
leg rests

Rigid Folding
• One-piece frame is comprised of • Two-piece frame connected with cross
bent and/or welded tubes bars for folding
• Leg rest hangers are integrated • Removable/swing-away leg rests

Why use a rigid frame? Why use a folding frame?

Generally lighter weight due to less User choice! If someone has been using
parts. This is significant for push a folding WC for a long time or just
efficiency and loading into vehicles. likes folding frame wheelchairs, then
Less parts can increase durability that is reason enough
Standing, or partial standing, transfers
More rigid equals more efficient. are easier with swing-away leg rests.
Folding frames will flex more which There are options on rigid frame
takes energy away from the push wheelchairs, but generally a folding
WC is easier for these clients
People who propel the wheelchair with
Rigid frame wheelchairs fit in small
their feet. There are options for rigid
areas as well! Consider a fold-down
frame wheelchairs, but they tend to
back & quick release wheels
require custom builds
If there is need for elevating leg rests
Transport efficiency for bariatric clients

Manual Wheelchair Guide 22

Manual
DME vs CRT
Wheelchair
Equipment
Guide

Tips for Justifying a K0005

Ultra lightweight MWC
HOW CAN I MAKE SURE THAT MY CLIENT GETS
THE MWC THEY NEED?

Qualification for a K0005 is functionally based, not

diagnosis based. Rule out a K0001-K0004 by documenting
why the “least costly” alternative is not effective. Include
a description of the client’s routine activities and whether
they are fully independent in the use of the wheelchair.
1. Use objective tests and measures such as a Wheelchair Propulsion Test
Compare an optimally configured ultra lightweight wheelchair vs. lower-end
wheelchair; time propulsion over a fixed distance; count push strokes; differentiate
quality of propulsion, document pain, pulse oximetery
2. Consider safety, efficiency, and ability to independently complete all mobility
related activities of daily living (MRADLs) all day, every day, with a lesser MWC
3. Consider the need to configure an ultra lightweight wheelchair for better posture
and mobility
4. Document the unique features of a K0005 and why they are needed:

• Adjustable front and rear seat- • Axle adjustability

to-floor heights • Seat slope
• Individualized seat and frame • Rear wheel camber
width and depth
• Seat back angle

Examples why the features may be needed:

Adjustable axle plate is required for center of gravity adjustment to allow for
efficient propulsion and decreased shoulder pain from 6/10 to 0/10.
Adjustable axle needed to allow for efficient propulsion compared to a
lesser WC: Person took 35 push strokes & 5 min to propel 40' to bathroom,
compared to ultra lightweight WC, where it took 15 push strokes & 2 minutes.
Additional seat size options are required as my client of 6’ and 170 lbs does
not fit the standard configurations of lower-end manual wheelchairs.

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 DME vs CRT Equipment

HOW CAN I GO ABOUT GETTING THE APPROPRIATE

WC WHEN CLIENT IS DISCHARGED SO EARLY?

This is a common challenge with inpatient rehab stays

getting shorter and shorter, but it is still possible.

The first thing to consider when doing your initial evaluation is whether or not
your client may need a wheelchair full-time when going home. If the answer
is "yes," treat your evaluation as if they are going to need a K0005 wheelchair,
even if they initially go home in a lower-end manual wheelchair for a short
period of time. What do I do?

1. Plan of Care - Include in the Plan of Care that the client is to follow up with the
next clinician in the continuum and the supplier after discharge to obtain the ultra
lightweight MWC that is recommended.
2. Talk to your client - Empower them by explaining that they are going home in a rental
wheelchair that will turn into a purchase in 12 months. Encourage them to talk to the
next therapist in the continuum about getting a better ultra lightweight wheelchair.
3. Rule out a K0001 - K0004 WC - Document using the methods outlined on page 22.
Documentation must show why the “least costly” alternative is not effective.

The rental wheelchair or demo WC from the dealer/ATP will buy time for
completing the evaluation and procurement process so your client can get the
wheelchair they deserve.

Remember to consider the 5-Year Rule. A client in a lower-end wheelchair that

isn’t going to meet their long-term needs is not the most beneficial option to
them. With the useful lifetime rules, a client must remain in the same WC for 5
years (longer with some funding sources), unless they have a change in medical
condition that warrants another new wheelchair.

Mobility needs upon discharge need to be considered

FROM DAY ONE of the rehab stay!!!

Manual Wheelchair Guide 24

ManualConfiguration
K0005 Wheelchair Guide

K0005 Ultra lightweight

MWC Configuration
WHAT ARE THE FUNCTIONAL CHARACTERISTICS
OF A HIGHLY-CUSTOMIZABLE WC?

Configuration options Why it matters

Front seat-to-floor height Important for safe functional use during propulsion
(FSTFH) Pages 27-28 and transfers
Rear seat-to-floor height Determines rear wheel accessibility and efficiency of
(RSTFH) Pages 27-28 propulsion
Seat slope: difference between Important for postural stability and optimal wheel
the FSTFH & RSTFH Pages 29-30 access for self-propulsion
Foot support-to-seat length This affects LE positioning, femoral contact for
Page 33 pressure redistribution, and foot plate clearance
Legs and feet brought closer to the body make the
Front frame angle
overall WC footprint smaller, making it easier to get
Page 34
close to things for reaching
Overall frame length A proper frame length ensures the wheelbase is
Page 60 proportional to the client
Affects posture, wheel access for propulsion, and
Seat width Page 35
environmental access
Seat depth Page 38 Optimizes posture and pressure redistribution
An optimal back support height will balance postural
Seat back height Page 40
stability and functional reach for ADLs
This angle provides optimal pelvic and trunk support
Seat-to-back angle Page 41
for stability and daily function
Horizontal & vertical rear This can be configured for optimal center of gravity
wheel axle position Pages 42-45 and wheel access for the most efficient push stroke

Rear wheels Page 49 Affects propulsion, rolling resistance, and weight

Rear wheel camber Page 50 Used to increase lateral stability and turning efficiency

Casters Pages 51-52 Stability, rolling resistance, and maneuverability

A K0005 is an individually configured, tailor-fit wheelchair.

It is not merely small, medium, or large.

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 K0005 Configuration

Measuring for a K0005

Ultra Lightweight Wheelchair
The features of a manual wheelchair will significantly affect the client
and performance of the wheelchair in terms of postural support and
wheelchair stability, maneuverability, and ease of propulsion.
This is why the ability to configure a K0005 wheelchair is best practice for a
person who uses a wheelchair long-term.

Relating the client's measurements to the wheelchair

specifications is key!

Anatomical measurements Wheelchair measurements

from mat evaluation to be performed with the person in a WC
seated in their desired position of propulsion

Manual Wheelchair Guide 26

K0005 Configuration

Seat-to-floor height (STFH)

The front and rear seat-to-floor height is not always the same in an
optimally configured K0005 MWC. (visual on next page)

Front STFH measurement

WC measurement is from where the leading edge of the seat upholstery
meets the frame of the wheelchair to the floor.

Anatomical measurement is meant to match the dimensions of the lower leg

along with the foot plate to ensure lower extremity support and accessibility.
• An appropriate height will provide proper support of the thighs and lower legs to
optimize stability and pressure redistribution

Rear STFH measurement

WC measurement is from the wheelchair frame seat tube to floor, right in front
of the back post. You must have the client in a WC to determine the RSTFH
• This height is meant to ensure appropriate access to wheel handrims for optimal
propulsion. Optimal RSTFH is when the finger tips of the client touch the axle of the
wheel. See "Vertical axle positioning" (page 45) for more
• A lower rear STFH relative to the front STFH can provide increased postural stability
for those with impaired trunk control

Foot plate height measurement

WC measurement is the distance from the top of the footplate to the seat
upholstery. It should be equal to the lower leg length minus the height of the
cushion. See page 33 for more.

Always consider the wheelchair seat cushion thickness

and clearance of tables and desks when measuring STFH!
For determining both the front and rear STFH, keep in mind that some
seat cushions may have a different thickness in the front and the rear of
the cushion. The difference will affect seat slope if not accounted for.

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 K0005 Configuration

FSTFH
RSTFH

Foot plate
height

USE A DEMO! All WC measurements should be completed

with the client in a demo wheelchair! The demo does not
have to be perfect for your client, but it will give the best
starting point for fitting them.

Manual Wheelchair Guide 28

K0005 Configuration

Seat slope

The seat slope is the difference between the front and rear STFH and is
important for postural stability and optimal wheel access for propulsion.

• The greater the seat slope from front to back, the more passive stability is provided
for those with decreased trunk control
• Consider available hip and knee range of motion when determining seat slope
• Insufficient seat slope may make sitting up difficult while too much seat slope may
make transfers more difficult

Seat slope
Sample - 2"

Front STFH
Sample - 18" Rear STFH
Sample - 16"

Most adults need about 2" seat slope if they propel with
their UEs. Foot propellers need 1/2" to 1" seat slope.

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 K0005 Configuration

Utilizing an ergonomic (ergo) seat

Sometimes a conventional seat slope won’t work for these reasons:
• There is an insufficient range of motion (ROM) at the hip and/or knee required
for the slope
• The individual requires 3" or more seat slope for stability and rear wheel access
With 3" or more of seat slope an acute hip-to-back angle is created so even a WC user
with normal ROM cannot access the rear portion of the seat
• Individual may feel unstable
• Individual complains of pain
• Individual complains of sliding forward

Example of limited ROM at the hip: Individual slides into an abnormal posture by shifting their
legs and pelvis forward to open the angle back up for comfort. Then, they slouch forward to
maintain their center of gravity/stability.

Manual Wheelchair Guide 30

K0005 Configuration

Ergo seat

An ergonomic seat is intended to match an individual’s shape while

providing a lower RSTFH relative to the front. The RSTFH is maintained
for a length of the frame before the seat tubing ascends up to the
FSTFH specified.

• This promotes an upright posture by maintaining a more open STBA compared to a

conventional seat slope
• It allows for better stability, positioning, and pressure distribution by creating a stable,
neutral place to seat the pelvis and load the femurs
• Allows improved rear wheel access for more efficient propulsion
• It optimizes total surface contact area, increasing pressure redistribution for the bony
prominences and encouraging pelvic stability
• The shape allows the thighs to be more level, making it easier to carry items during
daily tasks

Ergo seat measurement

WC measurement is from the back post of
the WC to the point in the tubing where you
want it to start to bend upwardly.

Anatomical measurement is from behind

the hip to the greater trochanter, plus 1 - 2".

Instability from an increased seat slope can be offset by

using an ergo seat when clinically appropriate for the user.

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 K0005 Configuration

The idea is to contain the ITs within the flat ergo well. Since the frame is providing
the positioning, the goals of the cushion need to be consistent with the goals of
the wheelchair. The cushion needs to follow the contour of the frame and provide
a flexible pressure relieving interface between the frame and the wheelchair user.

Ischial landing spot

3" ¾"

Conventional Ergonomic
seat slope seat

Manual Wheelchair Guide 32

K0005 Configuration

Foot support-to-seat length

The foot support-to-seat length is also known as leg rest length. It is

important to provide lower extremity support, ensuring optimal femoral
contact at the seat surface and clearance of obstacles at the footplates.
It is important to use a demo wheelchair with the person in the
desired position of propulsion, to get the most accurate measurement.

Foot support-to-seat - too short

• This can raise the knees which reduces
clearance for under tables and increase
slope of the upper legs which can make
it harder to carry items
• Can reduce femoral contact and
increase peak pressure at the ITs

Foot support-to-seat - too long

• Lower legs are unsupported and
pressure increases distal femur. The
client may slide forward to reach the
foot support, and by doing so, shift into
a posterior pelvic tilt
• This can increase risk of a postural
abnormality and peak pressures at the
seat and back support surfaces

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 K0005 Configuration

Front frame angle

Front frame angle is critical to provide appropriate support to the

lower extremities.

This should be set by asking the client

where they want their feet (further in or
out) and have the client place their feet
where they want them. The front frame
angle selected should be the one where
the ball of the client's foot can rest on the
foot rest tube. Measuring for the overall
frame length is a more accurate way of
determining the appropriate front frame
angle for a client. See page 60 for more.

Example visual: A tall individual may need to tuck their legs in tight under the WC due to their
longer lower leg length. This allows them to still clear the edges of tables, desks, counters and keep
their overall wheelchair footprint smaller. They must have an available ROM at the knee for this.

Manual Wheelchair Guide 34

K0005 Configuration

Seat width

Measuring the appropriate seat width is critical for postural stability

and propulsion efficiency.

Seat width measurement

WC measurement is outside to outside of seat tubes at the back post. This
should match the client's anatomical measurement.

Anatomical measurement is the widest point of the body at the hips including all
residual tissue.

• The seat width affects the overall

width of the wheelchair along with
wheels and handrims

Seat width

Seat width - too narrow

• This can lead to unwanted pressure and postural abnormalities due to compensation

Seat width - too wide

• This can make it difficult to access the handrims and result in inefficient propulsion
which can cause upper extremity injuries over time
• Negatively affects environmental accessibility and positioning/posture in the WC

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 K0005 Configuration

Front seat width

This measurement allows you to taper the front of the seat to match
the client's posture. Front seat width can also be referred to as the
seat taper.

Not all client's need to have a tapered seat. However, client's whose LEs are
much narrower than their hips may benefit from front seat taper to:
• Provide better LE positioning with better overall WC fit
• Allow the ability to get closer to things for transfers and reaching
• Provide a smaller overall footprint for accessibility
• "See me, not the wheelchair"

Front seat width measurement

WC measurement is inside of front frame tube to inside of opposite front
frame tube.

Anatomical measurement is the width across the client's legs across the distal
end of the femurs, proximal to the knees. This width should match the front
seat width measurement.

Seat taper starts

approximately 9"
from the back posts

Front seat
width

Manual Wheelchair Guide 36

K0005 Configuration

Footrest width

This measurement allows you to match the footplate with a LE

positioning that is comfortable for the client. Someone who has large
legs or LE edema may not need any front seat taper. Someone whose
lower legs are smaller than their hip width may need some leg rest taper.

Footrest width measurement

Select a width that allows for adequate space for the client’s feet and tapers to
the client’s desired position. Measure across both the client's feet with shoes.

Footrest Footrest
width width
(Standard) (V)

Standard - Inside of front frame tube V - Inside of front frame tube to inside
to inside of opposite front frame tube of opposite front frame tube 2 ½”
above footrest

Footrest width - too tight

• The tubes press on the client's legs or feet
• The footplate may not be wide enough to allow the feet to pivot for transfers if the
client leaves their feet on the footplate for transfers

Footrest width - too loose

• The client does not have adequate foot/LE positioning coming from the WC. Legs
and feet may lose position, especially with spasticity or going over bumps
• This can decrease environmental access by increasing the WC footprint

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 K0005 Configuration

Seat sling depth

The goal of seat sling depth is to maximize support and pressure

distribution without interfering with LE positioning. An appropriate
depth will provide optimal stability in the wheelchair.

Seat depth measurement

WC measurement is from the back posts to the leading edge of the seat
upholstery.

Seat depth

Anatomical measurement is from behind the user's hip including residual tissue
to their popliteal fossa AND should account for where they want to position
their legs, more or less tucked.

Seat depth - too short

• Decreases femoral contact for pressure distribution which can lead to pressure injury

Seat depth - too long

• This may result in sliding forward to decrease pressure behind the knees, resulting in
poor posture and decreased propulsion efficiency

Manual Wheelchair Guide 38

 K0005 Configuration

Frame depth

The frame depth is measured from the front of the back cane to the
front frame bend. The center point of the trailing front caster is usually
lined up with the front frame bend, resulting in a balanced wheelchair
for optimal stability and propulsion.

Frame depth

Frame depth on a rigid wheelchair should be set so that the bend in the
frame lines up with the bend in the user's leg. This results in a balanced
wheelchair because the front casters will move forward proportionally to
the end user's body when frame length is added to fit their shape.

If you notice anterior instability, caster loading, or

impaired maneuverability, check the frame depth!

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 K0005 Configuration

Seat back height

Proper back height in a K0005 is important for providing appropriate

postural support and upper extremity function for propulsion.

Seat back height measurement

The WC measurement is from the top
Seat back height
of the back post to the top of the seat
tube at the back post.

Select a seat back height that allows

the prescribed back support to
reach desired height to for adequate
postural support.

An optimal back support height is

determined by the lowest point of the
trunk needing support for stability
and function.

Back support - too high Back support - too low

• May limit scapular movement during • May result in a feeling of instability
propulsion which impacts upper • Individual may slide into a posterior pelvic
extremity range of motion tilt seeking stability. This can increase peak
pressures and promote abnormal posture

Manual Wheelchair Guide 40

K0005 Configuration

Seat-to-back angle

The seat-to-back angle (STBA) is critical for postural support and

assuring the best position for efficient propulsion. Most adults need
the STBA open a few degrees to allow room for their normal spinal
curves. This angle can be further adjusted to the client's needs using
adjustment on the back support mounting hardware and on the
wheelchair itself if available.

STBA measurement
On the WC, seat-to-back angle is measured from the front of the back post to
the floor.
90°
<90° STBA >90° STBA
Closed STBA Open STBA

• Greater than 90° may improve postural stability for individuals with impaired trunk
control and/or limitations in hip range of motion. 92° - 93° may provide the lumbar
area support for promoting normal spinal curves.

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 K0005 Configuration

Position of the rear wheel axle

The horizontal and vertical positions of the rear wheel axle, have
a significant impact on all of the functional characteristics of the
wheelchair such as:

• stability • turning radius

• weight distribution • wheel access

This also impacts the propulsion style, propulsion efficiency, and access to the
environment for the wheelchair user.

Keep in mind that a forward axle position reduces the forces needed to
propel and the rear axle should be set for the center of mass of the client.

Every full-time, long-term wheelchair user should have the

rear wheel positioned uniquely for them to prevent injury
and ensure full access to their environment.

Manual Wheelchair Guide 42

K0005 Configuration

Horizontal axle positioning

The horizontal axle position

will determine the wheelchair
center of gravity (COG).

When the axle is under the center

of mass of the client, the majority of
their weight is on the large rear wheel.
Ideally, this is about 80% of their body
weight. If weight is not on the rear
wheels, it will load the front casters,
requiring more force to roll the WC.

Horizontal axle measurement

WC measurement is the horizontal
distance from the front of the back
post to the center of the rear axle of
the wheelchair.

Best practice is to position the rear wheel as far forward as

possible without unsafe rear instability or caster interference.

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 K0005 Configuration

Forward axle Rearward axle

Rearward center of mass Forward center of mass

Benefits Benefits
Allows for more efficient upper The WC will be more stable in the rear*
extremity position for propulsion
Increases frontward stability of the WC. Considerations
WC is less likely to tip forwards when Less efficient upper extremity position to
rolling down, reaching forward, or reach rims, could lead to injury over time
scooting forward for transfers Increases the forces necessary to turn
Decreases turning radius and overall the wheelchair
footprint of the wheelchair, making it Increased rolling resistance makes it
easier to navigate small spaces harder to propel
Increases ease of performing a wheelie Increases difficulty of performing a
to maneuver obstacles wheelie to maneuver obstacles
Increases the turning radius and length
Considerations of the wheelchair footprint, making it
If too far forward, it increases the risk of difficult to navigate small spaces
wheelchair tipping backwards *Increases risk of WC tipping forward

Manual Wheelchair Guide 44

K0005 Configuration

Vertical axle positioning

Proper vertical axle position allows for optimal upper extremity position
for propulsion. Vertical axle position determines RSTFH measurement
and therefore affects seat slope.

Lower axle (on axle post) Higher axle (on axle post)
Higher RSTFH, less seat slope Lower RSTFH, more seat slope

Vertical axle measurement

The vertical position of the axle is
determined by how high or low the
RSTFH of the wheelchair needs to be.
Remember to account for cushion
thickness here.

For client's with hand function, finger

tips should touch the center of the
rear axle when sitting upright with
arms to the side. For those with
tetraplegia, use the thenar eminence
instead as your reference point.

Effective / efficient propulsion is affected if the vertical

position is too high or low, and it may place the upper
extremities in a position that could cause injury over time.

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 K0005 Configuration

MWC propulsion

The wheelchair configuration is critical for optimal push efficiency. The

goal is long, smooth strokes to decrease the frequency of pushing.

When propulsion forces and repetitions are minimized, the preservation of

upper limb function is maximized. This reduces the risk of discomfort, pain,
poor function, and injury.

The ideal seat height and axle position is when the angle between the upper
arm and forearm is between 100° - 120° when the hand is resting on the top
center of the pushrim.

— 100° to — 120° angle

Manual Wheelchair Guide 46

K0005 Configuration

Propulsion patterns

There are four push stroke techniques consisting of a push phase

and a recovery phase. The pattern of recovery (release to contact) is
the largest difference between techniques.

Contact
Release

Semicircular Single loop over

Arc Double loop over

The semicircular pattern is encouraged because:

• It promotes better biomechanics
• It is associated with lower stroke frequency
• It promotes more time in push phase than recovery phase
• The hand follows an elliptical pattern with no quick changes in direction and no
extra hand movements

Single loop over is the most common pattern for individuals with paraplegia.

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 K0005 Configuration

Propulsion efficiency

A forward axle position allows for longer, smooth push strokes which
will also decrease frequency of pushes.

Forward axle -
Distance between
contact & release

A rearward axle position reduces the user's ability to get a long stroke since
they are starting the push phase near the front of the rear wheel.

Rearward axle -
Distance between
contact & release

Manual Wheelchair Guide 48

K0005 Configuration

Rear wheel options

In terms of wheel type and size, the wheels are important to minimize
rolling resistance, decrease weight, and increase reliability of the system.

Rear wheel size

Diameter of the wheel is determined by the optimal RSTFH for a client.
For example, a taller person may need a larger diameter wheel.

Rear wheels - too large

• The seat-to-floor height and access to the hand rims may be compromised
• A larger diameter wheel may interfere with transfers since they create a little bit
bigger hurdle to transfer over
• A larger wheel will increase the length of the wheelchair footprint. This could
negatively affect client reach, ADLs, and wheelchair maneuverability

Tire styles
Pneumatic tires: (filled with compressed air)

• Weigh less
• Better shock absorption
• Need to be inflated properly for optimal propulsion

Non-pneumatic tire:
• May be solid or pneumatic with flat-free inserts
• Often used when a flat-tire could be a safety risk because the ability to properly
maintain pneumatic tires is in question

Choose a tire that is lightweight to decrease the initial force

required to turn the wheels. Low tread and the least amount
of surface contact to the ground decreases rolling resistance.

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 K0005 Configuration

Rear wheel camber

Camber is the inward tilt of the rear wheel. The camber angle affects
lateral stability and the efficiency of propulsion as well as rear wheel
access. When performing tasks that require leaning outside the
footprint of the wheelchair, increased camber will increase stability
and promote maintaining an upright position in the wheelchair.

Sample 0° Sample 4° Sample 7°

Most adult wheelchairs used for daily use have 0° - 3° of camber while
pediatric sizes may have more to improve wheel access. Wheel camber
decreases proximal distance to the user at the top for wheel while increasing
distance between wheels at ground level.

Sports WCs have greater than 3° degrees camber for stability. The extra wide
camber also increases the ease of propulsion (longer leaver arm).

Rear wheel spacing is the distance between the top of the wheel and the
back post. The goal is the narrowest possible configuration to allow the most
accessibility.

• Different amounts of rear wheel spacing is required for different camber angles
and wheel/tire configurations

Remember that adding camber will affect the overall

footprint of the wheelchair.

Manual Wheelchair Guide 50

K0005 Configuration

Caster options

Casters affect rolling resistance, stability, and maneuverability. The

key is to have proper axle adjustment to get most weight through
the rear wheel and decrease rolling resistance.

Caster size
Caster size affects FSTFH and seat angle of the wheelchair.

Small diameter caster Large diameter caster

Lower FSTFH Higher FSTFH

Most WC manufacturers will tell you which available caster sizes will work
when you are selecting the front frame angle and STFH.

The old way of thinking is that large casters roll easier. However, the
correct way of thinking is that less weight on the casters allow them to roll
easier. The key is to decrease as much contact with the ground without
compromising stability, while also having proper rear axle adjustments (rear
COG) to get the most weight on the rear wheel.

The goal is always to minimize rolling resistance.

To achieve this, choose a caster shape and size with the
least contact surface to the ground.

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 K0005 Configuration

Caster clearance /
Casters - too large
potential interference
• May hit the user's feet (overhead view)
• May interfere with the footplate and the
rear wheels

Casters - too small

• May make it difficult to go over obstacles

Caster - rear wheel & Larger caster with

foot plate clearance forward axle
Caster shape
Caster shape is also significant to their ability to roll. The less the caster
touches the ground the less rotational inertia it takes to make the wheel
turn. Most of the time, the wider the caster is, the more contact it has with
the ground. Some styles have a tapered shape so that when on a flat surface
the caster contact point is optimal. Then if the user rolls over a crack or into
a softer surface (e.g. dirt, gravel) they have more surface area to help them
when they need it.

Caster - too narrow

• May be difficult to manage rough terrain
• May have increased risk of getting caught. Example: cracks in sidewalks

Caster forks
Caster forks provide alignment and adjustment features of the casters for
stability, and maneuverability based on client's needs and preferences.
Suspension caster forks provide shock absorption.

Manual Wheelchair Guide 52

K0005 Configuration

Additional K0005 Ultra

Lightweight MWC options

There are a variety of additional options for K0005 wheelchairs

because they are truly the most customizable MWC option. Some are
for function, but may not be necessary for every client while others
are more client preference.

Configuration options Considerations

Affect use and propulsion (especially for those with limited
Handrim and
dexterity), otherwise may be heavily dependent on client
wheel lock style
preference
Affects safe foot placement/positioning
Foot plate style Options may include rigid, adjustable, swing-away, flip-up,
and flip-back
May be needed to promote postural stability
May provide a resting place to reduce fatigue
Arm rest (optional) Height can affect optimal wheel access
style, height, attachment Style can affect reaching and transfers
Options may include: adjustable, swing-away, flip-up,
and removable. Full and desk length
Consider for postural support and stability
Side guards (optional)
Can provide protection from the wheels during use
adjustable and/or
removable Reducing wheel resistance if wheels come in contact
with cushion, clothing
Safety feature for some environments and terrain.
Anti-tips
May be fixed, flip-up, removable
Will the client be pushed a fair amount of the time?
Push handles Can added push handles help them maneuver the WC
before and after transfer?

The setup of a K0005 MWC demands knowledge of client’s

history and potential for function. If not done correctly, the
client may not realize that they are at a disadvantage, and
it can have long-term effects. Understanding wheelchair
types and setup to maximize function will enhance their
life and also decrease the risk for complications.

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 MWC Power Assist

Power Assist
WHAT IS A WHEELCHAIR POWER ASSIST DEVICE?

Power assist is the use of technology to assist with

the “push” phase of independent manual wheelchair
propulsion. This technology can reduce the push
frequency and force required for effective mobility.
Power assist can be hub-mounted or rear-mounted. Both styles
allow for the rear wheels to be removed, but the weight of the
hub-mounted devices are significantly more because there are
two motors and batteries, instead of one. A rear-mounted power
assist does not require pushing to activate it which frees the
hands for function.

WHAT TYPE OF PERSON WOULD BENEFIT FROM

POWER ASSIST?

Although the common misconception is that power assist

is used for clients who have pain in their shoulders from
overuse, this is a REACTIVE way to use power assist.

What about those wheelchair users who want to be

PROACTIVE and use power assist to prevent an overuse
injury? Some examples include:
• The athlete who wants to continue in her sport and continue working
out for years to come
• The office worker who uses power assist to wheel several blocks to his
office, to maintain his energy throughout the day
• The elderly gentleman who has suffered a CVA who is a foot propeller
and uses power assist for efficiency

Manual Wheelchair Guide 54

Manual
MWC Power
Wheelchair
Assist Guide

Hub-Mounted
Power Assist
With this style of power assist, the
motors are in the wheels. They Hub-mounted device
are activated through force on (one side visible)
the pushrims. That force triggers
sensors which signal the motors to
propel the wheels forward.

Benefits Considerations
Can be programmed for sensitivity, Adds weight to the wheelchair
boost, and speed (up to 22lbs per wheel)
Wheels need to be removed to facilitate
Very little force is required to activate
transport in a vehicle
Need to protect the wheels during
Assist is on every push
transport, prevent damage to sensors
May offer slope deceleration assist which When the motors are not engaged (short
can help maintain a comfortable speed distances, select environments) the wheels
when going down grades and ramps add weight to every push
Can be used with folding or rigid MWCs If battery dies, adds resistance to wheels
Modifications to the WC may be
With programming, if there is a strength
necessary such as added hardware and
discrepancy from left or right, it may be
increased WC width, which could limit
able to compensate and maintain the
access to wheels and accessibility to
desired path
narrow spaces
Also require "power adaptable or power
reinforced frame" from manufacturer
Eliminates the ability to use wheel camber
Some users consider adapted vehicles
to avoid removing wheels for transport,
which is a considerable cost

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 MWC Power Assist

Rear-Mounted
Power Assist
This style of power assist is a
detachable, single motor component.
It attaches to the wheelchair axle and Rear-mounted device
wearable devices or controllers signal
the motor via Bluetooth or switches to
start, accelerate, and stop. Turning the
WC is still guided by the user's hands
on the handrims.

Benefits Considerations
Easily removed when transferring MWC User must be able to control rate of
into a vehicle, for transport, and charging descent down grades and ramps
On-demand function. Not necessary to Disc breaks can be added to the
have on the WC when not needed wheelchair to assist with deceleration,
(short distances & around the house) but are a separate device
Acceleration and top speed are Certain amount of training may be
programmable, allows for safe operation required for the user to safely operate
Programmable to meet different needs
Lightest weight option
Freewheels when off or if battery runs
out; minimally increased resistance
Does not compromise configuration of
the wheelchair, which is significant for
pushing without the device
Allows for more user-defined settings for
use in different environments and when
selecting input devices (control via Bluetooth
wearable or a hard-wired switch)
Weather-sealed / water-resistant
Can be used with folding or rigid MWCs
Can be used with manual tilt-in-space
wheelchairs to help caregivers

Manual Wheelchair Guide 56

Manual Wheelchair Guide
Conclusion

Conclusion
WHY IS A K0005 BEST PRACTICE FOR FULL
TIME WHEELCHAIR USERS?

A fully customizable wheelchair made of lightest

high-strength materials will:

• Decrease risk of upper extremity pain or injury

• Contribute to short and long-term functional success
• Decrease the incidence of secondary complications
• Last longer than standard wheelchairs
• All of the above also make them more cost effective

WHY IS IT IMPORTANT TO CUSTOMIZE

FRAME DIMENSIONS?

We maximize client potential through a custom fit.

The evidence-based recommendation from RESNA's position paper
"The Application of Ultralight Manual Wheelchairs" states that, "The
person cannot conform to the wheelchair, but the wheelchair must
conform to the individual." By doing this, we...

• Optimize roll efficiency of the manual wheelchair

• Reduce risk of repetitive strain injury over time
• Aid in postural alignment
• Reduce risk of pressure injury
• Improve function

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 Quick Guide - MWC Fit

Quick Guide - MWC Fit

Important considerations when completing wheelchair specifications:
• Choose the wheelchair you will use for the evaluation (the client’s existing
wheelchair or demo) – stay with this wheelchair throughout the measuring process
• Measure the demo being used for your records and as a reference for new
wheelchair specifications. Be sure to include overall width and overall frame length
– this is the functional footprint of the wheelchair and may be crucial for the client’s
environmental access and function
• Place the client in the demo wheelchair and ask the client to sit in their most typical
and desired position – the position they are in 80% of the time
• Now you are ready to complete your measurements using the selected wheelchair
as a reference, changing what needs to change for optimal configuration

Below is a model for how to achieve the best fit:

Width Length Wheel access

• Seat width Overall frame length - • Seat-to-floor heights
• Front seat width • Seat depth • Center of gravity
• Footrest width • Frame depth • Camber
• Front frame angle • Wheel spacing

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WC width quick reference

Seat width + front seat width + footrest width (standard or V)

Seat width Front seat width (seat taper)

Outside of seat tube at back post to Inside of front frame tube to inside
the outside of the opposite seat tube of opposite front frame tube

Footrest width - Standard Footrest width - V

Inside of front frame tube to inside Inside of front frame tube to inside
of opposite front frame tube of opposite front frame tube 2 ½”
above footrest

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WC length quick reference

Overall frame length = seat depth + frame depth + frame angle.

Using the overall frame length to determine the front frame angle is
the most accurate way of measuring for it.

Overall frame length Seat depth

Front edge of footrest to front edge of Front of back post to front of seat sling
back post

Custom frame depth Front frame angle

Front of back post to beginning of bend Frame front to floor (behind front frame)

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Dimensions & tips

Frame dimension

Seat width Width should only be as wide as necessary, allowing for use of
frame to promote postural alignment, improve wheel access, and
maximize environmental access
Seat depth Maximize support of the upper leg and pressure distribution
without interfering with posterior aspect of lower leg
Frame depth Match frame to client proportionally to the upper leg
Bend of frame should start at popliteal fossa
Ergo seat Select a size that goes at least 1” past the greater trochanter

FSTFH Must consider the cushion being utilized when selecting

Consider transfers, access under tables, desks, and clearance
required under foot plate
Seat slope is the difference in front and rear seat heights
RSTFH Use rear seat height to maximize wheel access and achieve a more
efficient push

Overall Select so that frame is proportional to the length of the client’s side
frame length profile while sitting in the desired position
or front
frame angle
Footrest Select a width that allows for adequate space for the client’s feet
width and tapers to the client’s desired position
Seat back Select a seat back height that allows the prescribed back support to
height reach desired height for adequate postural support
Seat back Select seat back angle that results in desired support, balance, and
angle optimal spinal curves when seated
Center of Ideally 80% of the client’s body weight on the rear wheel. Achieved
gravity this by bringing the rear wheel forward, reducing the amount of
weight on the front casters and improving wheel access
Camber Eases initiation of movement and turns, increases lateral stability
and, therefore, functional width of wheelchair
Wheel spacing May use in combination with camber to achieve a neutral shoulder
alignment during propulsion, impacts functional width of the WC
Wheel size Select a wheel size that allows for 100-120° of elbow flexion when
the client is at the start of a push stroke

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Pro tips are not all inclusive and do not take the place
Pro tip
of a skilled wheelchair seating and mobility evaluation

Matching the frame proportionally to the client results in better weight distribution
and unloading of casters, easing propulsion
For best results, your demo should have an ergo seat

Most adults require between 17-19.5” for front seat height

The more bend in the knee, the lower the seat to floor height required for adequate
clearance at foot plate

Must consider how much seat slope the individual can manage functionally and any
range of motion limitations. With client’s upper extremity extended down to the side,
middle finger should be at bottom of wheel hub
Consider hamstring length, spasticity, overall length of wheelchair
Overall frame length is inherently more accurate than choosing a front angle, so use
overall frame length in conjunction with seat depth and custom frame depth

Consider 0.5” on each side

Consider transfer style and types of footwear worn
Have your back support demo on the wheelchair

With the client’s upper extremity extended down to the side, middle finger should be
at center of rear axle, or with client in wheelie, caster should be 2" - 4” off ground
2.5” to 3.5” is typically a good starting point
Can negatively impact accessibility with adult wheelchairs if >3°

Set seat to floor height first in order to achieve postural stability and environmental
access. Then apply the correct wheel size for optimal wheel access

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Glossary

Glossary
Wheelchair & Parts Body & Posture
WC: Wheelchair PPT: Posterior Pelvic Tilt
WCs: Wheelchairs ASIS: Anterior Superior Iliac Spine
MWC: Manual Wheelchair PSIS: Posterior Superior Iliac Spine
MWCs: Manual Wheelchairs IT: Ischial Tuberosity
STFH: Seat-to-Floor Height ITs: Ischial Tuberosities
PMD: Power Mobility Device LE: Lower Extremity
FSTFH: Front Seat-to-Floor Height LEs: Lower Extremities
RSTFH: Rear Seat-to-Floor Height UE: Upper Extremity
STBA: Seat-to-Back Angle UEs: Upper Extremities
COG: Center of Gravity Process
ELR: Elevating Legrest LMN: Letter of Medical Necessity
Client Function DME: Durable Medical Equipment
ROM: Range of Motion CRT: Complex Rehab Technology
ADLs: Activities of Daily Living POC: Plan of Care
MRADLs: Mobility Related CMS: Centers for Medicare & Medicaid
Activities of Daily Living Services
People
ATP: Assistive Technology Professional
MD: Medical Doctor/Physician
NP: Nurse Practitioner
CNA: Certified Nursing Assistant
PA: Physician Assistant

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 References

References

1. Paralyzed Veterans of America Consortium for Spinal Cord Medicine. Preservation

of upper limb function following spinal cord injury: a clinical practice guideline for
health-care professionals. J Spinal Cord Med. 2005;28(5):434.
2. Arledge S, Armstrong W, Babinec M, et al. RESNA Wheelchair Service Provision
Guide. Arlington, VA: Rehabilitation Engineering and Assistive Technology Society
of North America; 2011.
3. World Health Organization. International Classification of Functioning, Disability and
Health (ICF). Geneva, Switzerland: WHO Press; 2002.
4. Dicianno BE, Lieberman JMLA, Schmeler MROLA, et al. Rehabilitation Engineering
and Assistive Technology Society of North America’s Position on the Application
of Tilt, Recline, and Elevating Legrests for Wheelchairs Literature Update. Assist
Technol. 2015;27(3):193-198.
5. Cowan RE, Nash MS, Collinger JL, Koontz AM, Boninger ML. Impact of surface type,
wheelchair weight, and axle position on wheelchair propulsion by novice older
adults. Arch Phys Med Rehabil. 2009;90(7):1076-1083.
6. DiGiovine, C., Rosen, L., Berner, T., Betz, K., Roesler, T. and Schmeler, M. (2012).
RESNA Position on the Application of Ultralight Manual Wheelchairs. [online] Resna.org.
Available at: https://www.resna.org/sites/default/files/legacy/resources/position-
papers/UltraLightweightManualWheelchairs.pdf.
7. Ogilvie, C., Khalili, M., Van der Loos, H. and Borisoff, J. (2018). How do Mobility Add-
Ons Change the Loading Conditions on Manual Wheelchair Frames?. [online] Resna.org.
Available at: https://www.resna.org/sites/default/files/conference/2018/emerging_
technology/Ogilvie.html.
8. Thomas, L., Sparrey, C. and Borisoff, J. (2017). Defining The Stability Limits Of A
Manual Wheelchair With Adjustable Seat And Backrest. [online] Resna.org. Available
at: https://www.resna.org/sites/default/files/conference/2017/wheeled_mobility/
Thomas.html.

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www.permobilus.com
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