The wheelchair selection process of getting fitted for and choosing the best seating system (wheelchair, cushion and backrest) can be a daunting process. To help you make the most out of the next time you select a wheelchair, or to maximize the fit and performance of your existing chair, we put together a list of questions that address information we wish we knew when we started out, and posed them to three longtime experts in the wheelchair industry. 

Our list of experts:  

Rory Cooper is the founder and director of the Human Engineering Research Laboratories, FISA Foundation, a Paralyzed Veterans of America Distinguished Professor at the University of Pittsburgh, and a senior research career scientist at the U.S. Department of Veterans Affairs. He is in his 45th year as a T7-8 para. 

Justin Kimrey has been a full-time assistive technology professional for Stalls Medical in Raleigh, North Carolina, for 12 years. He is in his 22nd year as a T12/L1 complete para. 

Jenny Lieberman is the senior clinical specialist for wheelchair seating and positioning at the Department of Rehabilitation and Human Performance at Mount Sinai Hospital. She has a Ph.D. in occupational therapy, has been an OT for 29 years and has held an ATP certification for 21 years. 

New Mobility: When you’re eligible for a new wheelchair, what preliminary steps should you take to make sure you end up with the best wheelchair for your needs? 

RC: Consult with a peer group or local advocacy group and ask who to go to for a seating clinic and ATP/DME vendor. If you have an opportunity, try different chairs to see what you like. Have your list of what you want, but keep in mind that no single chair will meet 100% of your expectations and needs.

JL: Do your research, ask your friends, go to shows like the Abilities Expo, find what makes you feel “good” and then work with your team of therapists and seating professionals to ensure a holistic setup of design and support. The main consideration should be stability and support, and insurance only considers what’s medically necessary. Keep this in mind as your team makes recommendations for coverage while trying to meet your personal needs.  

JK: If there are several DME’s in your area, call all of them and see which one you like. An important question to ask the DME vendor is, “Is the ATP you will be working with willing to spend time with you at the vendor showroom (if there is one) looking for the equipment you are interested in?” 

JL: Insurance will only pay for a new chair every five years. If you aren’t able to find a good seating clinic and wheelchair dealer in your area, it is worth a long drive and night or two in a hotel to get the proper fit and setup. Unfortunately, across the nation there are a lot fewer seating clinics than there were 20 years ago. 

JK: Choosing the right equipment should be a win/win, team approach with the therapists and technicians you work with — but at the end of the day you are the boss. If your team isn’t aligning with your needs, find a new team. 

RC: You want to be organized so that you can participate in or lead the process, and not miss anything critical. Know what your needs are and be able to articulate them clearly. Create a list of the activities that you perform or wish to be able to perform. Know and be able to describe the challenges you are encountering. If you currently use a chair, list what works well for you and what could be improved.  

JL: Before you go to your evaluation, create a list of what you want and what you need in a chair, but also be open to the team’s recommendations and their advice. We try and match what the person wants, but sometimes we can’t. Discuss with your team why the choices of chair and setup are being made, so you are all on the same page. 

NM: What are the key considerations for fitting a wheelchair to best suit your needs? 

JK: Depending on how long you’ve been a wheelchair user, you’ll probably have different needs or considerations. A new user is usually concerned about weight, function, caregiver concerns and comfort. A more experienced user may be concerned about degree of custom options for a more precision fit, durability, weight and appearance. 

RC: Form, function, and fitting into your lifestyle. Cost should be a secondary factor. The chair needs to make you mobile and support your activity lifestyle. You want to make sure you can use it in your home and community. Also, how easy is it to perform transfers and common activities of daily living?  

JL: The first thing is you want to be sure you feel stable. You should have a good balance point where you can lift your hands up and reach and do things without feeling like your body is going to fall over or the chair is going to tip over. The next thing is whether the wheelchair is comfortable and protects your skin integrity. Those are harder and take sitting time to determine. 

NM: How do you find the best blend of enhancing function and posture? 

RC: Ideally, they go hand in hand. You want to be careful about adding too many accessories. I’ve seen too many people use a quality chair that has been hampered by adding every possible accessory. I prefer to be a minimalist to improve function and reliability.  

JL: As a therapist, we do a proper physical assessment to determine range of motion and postural limitations, both with and without gravity (i.e., lying down versus sitting up). Once we know how gravity affects alignment and have true range measurements, we can problem-solve what types of cushions and backs will allow for the best support. Then we try the products, having consumers actively reach, propel, etc., to ensure that we aren’t interfering in how they are currently performing mobility-related activities of daily living. 

JK: Ask questions. Communicate with your ATP and your seating therapists. When a client asks lots of questions, I know I’m getting things right because we are discussing every decision. 

NM: Are there any seating options that are often overlooked or undervalued by inexperienced technicians/therapists? 

JK: Selecting the proper cushion is especially important since your insurance will only pay for a cushion every five years. Ask your ATP and your peer support group how well a cushion holds up over the long haul. If it starts to break down, you are at risk of a pressure ulcer. Ask to be able to have your choice of cushion pressure-mapped prior to purchasing. *  

JL: I’m a big proponent of rigid back support — it is good for support and alignment and is much more efficient for propulsion, much like the reason track athletes push off of starting blocks. 

* If insurance doesn’t pay for a cushion when needed, ask if you can get a discount for cash or look online. It is better to pay out of pocket than be stuck in bed fighting a pressure sore. 

How do you make sure that wheelchair measurements/frame choices are working with component choices like cushions and backrests? 

JK: You should order all of your components together to get the best fit. You don’t have to use the same manufacturer for your chair and cushion, or your backrest and chair. Order what works best for you and ask your ATP to make sure the components fit the frame. 

RC: Several manufacturers will send you or the clinic drawings to review to verify that everyone is on the same page. Ask to see these. Whenever possible, try a demo chair that is the same as or very close to the chair that you want to use.  

NM: What is the most critical setting/configuration to get right? What is the most common mistake to watch out for? 

JL: Because you want to feel stable in your chair, the most critical settings are center of gravity, depth (length of seat-sling) and width and knee-to-heel measurement (footrest length). For center of gravity, you want the rear wheel far enough underneath you to have good shoulder and arm movement for maximum pushing efficiency, but you don’t want it so far forward that the chair becomes too tippy and there is a safety risk. For new wheelchair users, optimum center of gravity tends to change (move forward) as their wheelchair-handling skills improve. 

Depth and width go hand-in-hand. If the frame is too deep (long), you sacral-sit and don’t get good back support; too short and you don’t get enough thigh support and get increased pressure into the buttocks. If the frame is too wide, the wheels are too far away and this will impact shoulder integrity when you push; too narrow can result in pressure injury on the sides of your hips.  

RC: Settings/configuration should focus on maximum function for the wheelchair user’s abilities, which usually improve (better balance, stronger arms) in the early months and years after an injury. A common width-mistake some clinicians make is using a “2-inch rule,” meaning the seat width should be 2 inches wider than the person’s hips. A good rule of thumb for width is to be able to slide a hand (roughly ½ to 1 inch wider) between the side guard and trochanter (hips).  

JL: For seat depth, for you want as much femoral support as possible. When seated with your feet on the footrest, you want about an inch of clearance behind the knees.  

JK: You should have enough space between the end of the seat pan and the back of your legs so you are able to tuck your feet straight down or even a bit behind without touching the seat pan or cushion. 

For knee-to-heel (footrest height), make sure your feet are fully supported and your thighs are loading onto the cushion. If the footrest height is too short, your knees will be too high and there is more direct pressure into the buttocks. Likewise, if too low, your feet will be hanging and interfere in balance and stability.  

I like my feet to be able to tuck back, so my toes are equal to the front of my footrest to make a smaller turning footprint. Also, if my feet are sticking out further, I risk catching a toe or foot on something when I’m turning, which could result in a broken toe or tibia/fibula.  

Ask how the foot box (footrest area) is measured. Is it measured from the inside of the tubes or the outside of the tubes? This makes a big difference, and you don’t want a foot box that is too small. 

RC: The most common goal mistakes are: adding too many accessories, ordering a frame that is too wide, a seat that is too flat, and/or setting rear axles too far back. For rear axles, a rule of thumb is when sitting upright in the seat with your back against the backrest, your middle fingers should be at, or just below the rear axles. This is a good starting point for both fore-aft and seat height/dump variables. 

In terms of a seat that is too flat, the seat dump is a trade-off between propulsion, transfers and and functional tasks. The most common initial setting of seat dump is the rear of the seat at about 1 ½ – 2 inches lower than the front, which results in a fairly flat seat. For transfers, this flatter setting (less dump) tends to be better, as it brings the seat height up and makes it easier to move to the front portion of the seat. Athletic users and more skilled wheelchair users tend to go with 3 inches of seat dump. Caveat: This is for the average adult chair with a seat pan depth of 16 to 18 inches. 

JK: The two fit configurations I see that should be avoided are (1) ordering a chair frame that is too wide or (2) too deep, meaning the seat pan (sling seat) is too long. For me, too deep is the worst. When the seat pan is too long, your chair is going to be significantly longer than needed, which makes it heavier and more difficult to transfer. 

NM: What are the pros and cons of an adjustable frame versus a more fixed one?  

JK: The pros of an adjustable chair are being able to set it up for stability if you are a new injury, then after six months or a year later you can readjust the chair so it feels sportier, like a whole new chair. The main con is that it is usually heavier. 

The pros of a fixed frame chair are it’s quieter, lighter and stronger than an adjustable chair. The downside is you have to get the measurements perfect. Another downside for a fixed chair is they are more expensive and usually insurance won’t cover it.  

RC: Fixed chairs are more responsive and less likely to break down. However, they need to be fitted very carefully and should not be the first chair.  

JL: Usually, by your third chair, going fixed is a better option because there are fewer moving parts, propulsion is more efficient, and there is less upper-body wear and tear and back strain. Also, a fixed frame chair lasts and lasts and lasts. If you are super active and throwing your chair in and out of the car, it is hard on the chair, so you need a chair that will last. 

NM: Any advice for navigating insurance and Medicaid? 

JL: Get your insurance plan and read it so you know what they cover and under what circumstances. You can look up Medicaid and Medicare coverage easily online.  

RC: Seek advice from organizations like United Spinal’s Resource Center and your local center for independent living. If you have any doubts about eligibility or benefits, bring an informed and vocal advocate to your clinical appointment. 

JL: If you get a denial: appeal, appeal, appeal, advocate, advocate, advocate. Insurance is counting on you accepting a denial, and more often than not people just accept the denial. If you appeal, you have a chance of getting what you want, and it sends a message for you and for others that the equipment you are advocating for is important.  

JK: Ask your therapist, ATP and peer support group for advice for advocating. The ATP, the clinician and the doctor will be happy to send the insurance company paperwork they request, but an appeal from a customer goes a lot farther than anything an ATP or clinician can do. You are the insurance company’s customer. They work for you. 

JL: When insurance companies don’t see any appeals or denials, it reinforces their decision that they were right to deny. 

NM: What’s the one piece of advice you’d give to help someone ensure they get the best seating setup possible? 

JL: Unfortunately, insurance impacts a lot of our decisions and only considers what’s medically necessary. Keep this in mind as your team makes recommendations for coverage while trying to meet your personal needs. While there are some limitations to what insurance will reimburse, often (not always) you can pay for what you want even if you can’t get it through insurance. Exploring other means of funding is a good thing to look into, like grants, GoFundMe, local organizations.  

JK: Ask if you can see a computer aided design (CAD) drawing before your chair is built. Some manufacturers offer this; some do not. When your chair is delivered, if it is not right, or is not complete and correctly adjusted, do not sign for it! It is your right to refuse a chair until it meets your satisfaction. Once you sign for it, it’s yours. 

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