The pushrim-propelled wheelchair is light, easy to steer and has good indoor manoeuvrability but is very inefficient and causes serious upper body overloading so that long-term use leads to steadily deteriorating capability for the user and ultimately a transition to a powered chair. Whilst the latter is less physically demanding, the sedentary lifestyle and decreasing muscle use lead to several secondary health problems. Crank- and lever-propelled wheelchairs and geared pushrim wheelchairs are more efficient and less demanding and may improve the quality of life of the user by expanding the range of accessible environments, reducing upper body pain, increasing independence and avoiding or delaying the 'debilitating cycle'. However, wheelchairs with these alternative modes of propulsion are often heavier, wider and/or longer and are less easy to steer, brake and fold than the pushrim wheelchair. Implications for rehabilitation Pushrim-propelled wheelchairs are difficult to drive on outdoor paths (grass and gravel/sand surfaces) and ramps so that users are confined to restricted environments and have limited participation in everyday activities. The repetitive strain imposed on the upper body by pushrim propulsion leads to very high prevalence of shoulder and wrist pain in manual wheelchair users. Crank-propelled and lever-propelled wheelchairs are more efficient and less straining than pushrim propelled wheelchairs, allowing users to access more challenging environments, prolong independence and improve the quality of life.

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