Wheelchair and Mobility-Aid Repair Level 2

Who it is for. People who have finished Wheelchair and Mobility-Aid Repair (Level 1), or who already repair wheelchairs and can show the same skills, including wheelchair users, family carers, bicycle repairers and community rehabilitation volunteers. National Proficiency II prepares people for mostly routine work under limited supervision and leads to National Certificate I.

Bridge from Level 1: what you already know

Level 1 left out measuring and fitting, truing wheels, castor flutter, frame inspection, making cushions, teaching users, follow-up, fitting crutches and frames and refurbishing donated chairs. Level 2 covers all of these.

How the module works

Each unit has learning outcomes, performance criteria, the range and the evidence your assessor needs. You are judged Competent or Not Yet Competent. About 70% of the time is practical. Each unit ends with Check yourself and homework. WHO's 2023 guidelines say wheelchairs should be provided through individual assessment and selection, then prepared and fitted for each person, with user training and ongoing follow-up. This book teaches the repairer's part of that work.

Competency standard

Range. Two users who can sit upright; manual wheelchairs with some adjustment. Evidence. Measurement forms; fitting checklists; observation of a fitting.

Where the repairer fits in

WHO describes eight service steps: referral and appointment; assessment; prescription (selection); funding and ordering; product preparation; fitting; user training; maintenance, repairs and follow-up. Technical staff assemble, adjust, modify, maintain and repair chairs, and help with selection because they know the products; where a user's needs are complex, the technical person should work alongside the clinical person. At Level 2 you prepare and fit; you take part in assessment and selection only together with a trained assessor, and only for users who can sit upright.

Take the five measurements

You need: a retractable metal tape, two clipboards or stiff books, foot blocks, the measurement form.

Before you start

1. Explain what you will do and why, and ask permission.
2. Work in a quiet, private, clean place.
3. The user sits as upright as possible, feet flat on the floor or on foot blocks, wearing the shoes they wear most days. Empty their pockets.
4. Hold the tape straight and bend down to read it level.

Remember to allow for the height of the cushion the user will sit on.

Prepare the chair

Prepare in this order:

1. Check the seat width and depth match the prescription.
2. Check the cushion width and depth match the seat.
3. Adjust, where possible: backrest height and angle, armrest height, rear wheel position, brake position, footrest height, push handle height.
4. Do the full safe-and-ready check (Level 1, Unit 2).
5. Label the chair with the user's name.

Fit the chair: the four checks

Wherever possible the person who did the assessment should do the fitting. Fit in this order: size and adjustments, then posture, then pressure, then fit while moving.

Then check posture from the side and the front: is the user sitting upright comfortably? Check pressure for every user at risk (Unit 4). Finally check while moving: does the backrest let the shoulders move, do the feet stay on the footrests, is the rear wheel position right? Write any further actions in the user's file.

Simple fit problems you may solve

These solutions from WHO's Basic level package assume the closest-size chair has already been chosen. Do them only for users who sit upright, and only with your supervisor's agreement.

Check yourself

1. How do you turn the seat-depth measurement B into a seat depth?
2. What gap should there be between the back of the knee and the cushion?
3. What must you always do after moving the rear wheels?

Competency standard

Range. Spoked rear wheels from at least two chairs; one quick-release axle. Evidence. Before-and-after measurements; job cards; observation.

How truing works

Truing means changing spoke tension with a spoke wrench to make the wheel straighter (side to side, "lateral") and rounder (up and down, "radial").

Set-up. Use a truing stand if you have one. If not, fix the wheel on its chair (chair upside down or on its side) and fix a pointer, such as a cable tie or a pencil taped to the frame, close to the rim.

Side-to-side (lateral) truing

1. Spin the wheel and bring the pointer in until it just touches the rim. Note where it touches.
2. At the centre of that spot, choose the spoke that comes from the hub flange on the opposite side to the pointer.
3. Tighten that spoke's nipple about a quarter turn (up to half a turn for a big wobble, an eighth for a small one).
4. Repeat for the next biggest wobble on the same side. After about three corrections, work from the other side.
5. Prefer tightening to loosening: loose spokes loosen further, but tight spokes do not tighten themselves.

Up-and-down (radial) truing

6. Find a high spot (the rim moves towards the pointer from above).
7. Tighten an even number of spokes in that area from both flanges, about half a turn each, so you do not create a new side wobble. For a low spot, loosen the spokes there.
8. Check side-to-side truth again every 3 or 4 radial corrections.

Good enough: about 0.5 mm side-to-side (about 5 sheets of paper in the gap at the worst spot) and about 1 mm up-and-down. A tyre limits how exact you can be; stop when changes give little gain.

Replace a broken spoke

1. Remove the tyre and tube (Level 1). Check the rim strip.
2. Remove the broken spoke and its nipple.
3. Take the old spoke (or one next to it) to the shop to match length, thickness and head shape.
4. Thread the new spoke through the hub flange in the same direction as its neighbours (head in or head out), following the same crossing pattern.
5. Screw on the nipple by hand, then tighten until it feels like its neighbours.
6. True the wheel (above). Refit tube and tyre.

(Teaching method; the truing steps are from Park Tool.)

Overhaul a hub and axle

1. Remove the wheel. Lay washers and spacers in order on a tray.
2. Tap out both bearings (Level 1, Unit 4). Clean the hub and axle.
3. Roll the axle on a flat surface: if it wobbles, it is bent and must be replaced.
4. Fit new sealed bearings of the same number and seal type, pressing on the outer ring only.
5. Refit, tighten until there is no side play but the wheel spins freely.
6. Quick-release axles: clean off oil and grit with a dry rag and a little lubricant; the axle should come off easily and the locking balls should engage fully. Check quick-release axles are secure at least once a month.

Check yourself

1. To pull the rim away from a pointer on the left, which spokes do you tighten?
2. How much do you turn a nipple for a normal correction?
3. How do you know a rim is too bent to true?

Competency standard

Range. Three chairs with castor, brake and frame faults. Evidence. Fault-finding records; job cards; observation.

Castor flutter: find the cause

Each castor stem usually has two bearings; a full set for an adult chair is four castor wheel, four stem and four rear hub bearings. Remove hair and threads from castors and forks at every service.

Rebuild a brake

1. Check tyre pressure first; soft tyres stop push-on brakes working.
2. Check the lever pivot: worn holes or a bent arm make the brake slip. Replace worn pins, springs and bars.
3. Clean and lightly oil the pivots.
4. Set the brake bar the same distance from each tyre so both sides hold equally.
5. Push test with the brakes on, both forward and backward. Spin test with them off.
6. If the rear wheel position has changed, set the brakes to the new position.

Folding frames and frame tubes

• Cross-folding chairs can weaken at the folding joints, making the chair feel unstable and harder to push. Check every cross-brace pivot bolt for play and wear.
• Rust weakens metal and can make parts break and injure the user. Remove rust with sandpaper or a steel brush, clean with thinner and a cloth, and repaint.
• Look for cracks, dents, bends and damage, especially near welds, the axle plate, the footrest hangers and the cross-brace.

Decide: repair, refer or retire

WHO names welders as one of the local trades that can help with wheelchair repairs. The welder must know what the frame is made of and must not weaken it. Learn welding properly in the Hub's Basic Welding course before you attempt any frame repair yourself.

Check yourself

1. Name three causes of castor flutter.
2. What do you do with a chair that has a crack at a weld?
3. Why must brakes be reset after moving the rear wheels?

Competency standard

Range. One adult and one child-size cushion; one pressure test on a volunteer at risk (with consent). Evidence. Finished cushions; pressure test records; observation.

Cushion types

A foam pressure-relief cushion has a firm base and a soft top "comfort" layer. Its shape usually has a well under the seat bones and a shelf in front of them to keep the pelvis upright and stop sliding.

Make the cushion: step by step

Size. WHO's example cushion is 400 mm wide × 400 mm deep × 50 mm high, with a seat-bone well 200 × 200 × 35 mm, for a seat 400 mm wide. For other users:

• well width = half the seat width, or 200 mm, whichever is less;
• well depth (front to back) = half the seat width, or 200 mm, whichever is less;
• well height = 35 mm for adults, 20–25 mm for children.

You need: firm base foam (for example "chip" foam), soft comfort foam, a dark marker, a long knife or sharpened hacksaw blade, contact glue, a ruler.

1. Mark the cut lines on all six sides of the base foam. The centre of the well must be on the centre line of the cushion, at the back.
2. Cut the well with long, slow strokes, cutting mainly on the pull stroke for control. First cut through the back to the well depth, then slice out the well.
3. Glue back the two side "flaps" left beside the well. Wait until the glue is tacky, not wet, then press together.
4. Bevel (cut off at an angle) the inside corners of the well.
5. For a slung seat, cut an angled bevel along both sides of the underside (WHO shows about 15 mm), so the base sits on the curved sling and the top stays flat.
6. Add the top layer. Put base and top layer in the cover together; they need not be glued. A soiled top layer can be washed or replaced.

The cover

• Stretchy fabric if possible; water-resistant fabric is very good if it is not too thick.
• Removable for washing.
• Loose or stretchy enough that the seat bones can sink into the foam; thick folds can mark the skin and cause a sore.
• If there is no water-resistant fabric, a very thin plastic bag inside the cover can protect the foam, but check it has no creases, does not make the user slide, and that fluid does not pool on it.

The hand pressure test

Do this for every user at risk of pressure sores, on their chair and cushion.

1. Explain what you will do and why. Get consent.
2. Ask the user to push up or lean forward. From behind the chair, reach under the back upholstery and place your fingertips, palm up, under one seat bone.
3. The user sits back on your fingers, normally, facing forward, hands on thighs.
4. Judge the level:
   • Level 1 = safe: your fingertips can wriggle up and down 5 mm or more;
   • Level 2 = warning: fingertips cannot wriggle but slide out easily;
   • Level 3 = unsafe: fingertips are squeezed firmly and hard to pull out.
5. Repeat under the other seat bone.

If level 2 or 3: add a lift: a layer of firm foam about 20 mm thick, with a hole cut under the seat-bone area, placed under the cushion inside the cover. Test again; add another layer if needed. Also check that the seat bones sit inside the well, not on its edge.

Check yourself

1. What are the three pressure test levels?
2. What do you add for a level 2 or 3 result?
3. Why must a cushion never be used back-to-front?

Competency standard

Range. Two users or role-play partners; one follow-up visit or call. Evidence. Training checklist; follow-up form; observation.

What to teach

WHO's package lists six areas: handling the chair; getting in and out (transfers); mobility skills matched to the user; preventing pressure sores and what to do if one develops; caring for the chair and cushion at home; and what to do if there is a problem. WHO's 2023 guidelines recommend training in skills, use of the chair's parts and how to guide helpers, and, conditionally, in maintenance and repairs.

How to teach: find out what the user already knows; explain, demonstrate, then let them practise; use language everyone understands; let users teach other users; be encouraging. Ask the user whether they want a family member or carer to learn too.

Mobility skills (with a spotter)

Transfers

• Brakes on before every transfer. Footrests out of the way; armrest off on the transfer side.
• Lift, do not drag: dragging damages skin and can cause a sore.
• A transfer board helps people with weaker arms move in small lifts. It can be made locally from strong, smooth wood or plywood, about 300 × 600 mm and about 20–25 mm thick, thinner at the edges.
• Helpers: make sure you can support the person's weight; explain first; use safe lifting; do not help if you are pregnant or have a back problem.

The home-care checklist

Give each user a card with WHO's home-care jobs: clean the chair and cushion; oil moving parts; pump tyres; tighten nuts, bolts and spokes; check upholstery, rust and the cushion; and know what to do if repairs are needed or the chair stops fitting.

Follow-up

Follow-up checks how the user is getting on, whether the chair is in good order and whether it still fits. It matters most for children, users at risk of pressure sores, users with a progressive condition, and users who found the training hard.

• One follow-up within six weeks of delivery is often useful; for children, ideally every six months, because they grow.
• Follow-up can be a home visit, a centre visit, or a phone call if transport is hard. WHO's 2023 guidelines describe health workers sending photos or video of the user in the chair to a distant adviser, with the user's informed consent.
• Signs that a user needs follow-up include pain, weakness or stiffness, recent falls, new pressure injuries, difficulty with daily activities or pushing, and a chair that needs repair.

Follow-up form (adapted from WHO): Are you using the chair as much as you want? Any problems? Any questions? Any pressure sores (where, what stage)? Satisfaction 1–5. Is the chair safe? Is the cushion safe? Does it still fit? Pressure test level (if at risk). Sitting upright through the day? Actions.

Check yourself

1. Name the six areas of user training.
2. When is a first follow-up often useful, and how often for children?
3. Why must a user lift rather than drag during a transfer?

Competency standard

Range. One pair of elbow crutches, one frame, one tricycle, one donated wheelchair. Evidence. Fitting records; tricycle job card; refurbishment record.

Fitting crutches and frames

Stairs teaching (crutches). Going up, a user who can bear weight steps up with the unaffected leg first, then brings the affected leg to the same step; use the handrail and one crutch, or both crutches if there is no rail.

Hand tricycles

1. Chain: check wear with the ruler method (Level 1). Single-speed chains are replaced at about 1% wear, and the maker's figure takes priority. Replace a worn chain before it wears out the sprockets.
2. Brakes: pads, cables and levers; test on a slope with the rider seated.
3. Steering: no play in the head; hand cranks turn smoothly.
4. Wheels: true and spoke-check as in Unit 2.
5. Seat: firm, with a cushion for riders at risk of pressure sores.

Refurbish a donated wheelchair

WHO warns that without systems to refurbish and recycle wheelchairs and parts, resources are wasted. In the Oti Region, donated chairs left outside for years had faulty castors, push rims, anti-tip bars, heel loops and footplates.

1. Record the chair: make, size (seat width and depth), serial number if any, photos.
2. Strip cushions and upholstery. Clean the whole chair.
3. Inspect the frame (Unit 3): repair, refer or retire. Never refurbish a cracked frame.
4. Replace all worn bearings, tyres, tubes, ferrules on footrests, brake parts and missing bolts.
5. True both wheels; service quick-release axles.
6. Upholstery and cushion: new or repaired upholstery; new cushion or new foam.
7. Safe-and-ready check, then label "Refurbished, ready for fitting, seat ___ × ___ mm".
8. A refurbished chair goes to a user only after measurement and fitting (Unit 1). WHO says each chair must be prepared and fitted for each person.

Check yourself

1. Where should an underarm crutch top sit?
2. At what chain wear is a single-speed chain usually replaced?
3. What must happen before a refurbished chair goes to a user?

Competency standard

Range. The trainee's own service plan. Evidence. Price list; parts stock list; partner list; marketing plan.

Your services and prices

Set your prices from your costs (Level 1), and write them on a board and on WhatsApp. Users in Oti said repairs of about GH¢300 a chair were too costly for them: offer a cheap basic service, payment plans and partner funding.

A parts stock

Keep a small stock of fast-moving parts so a user does not wait: tubes and tyres in the two most common sizes, castor wheels, sealed bearings in the common numbers (read them off the chairs you see), spokes and nipples, brake parts, bolts and nuts, Velcro straps, ferrules in common sizes, cushion foam and fabric. Record each part in and out in a stock book.

Partners

Location settings that give good returns

Market yourself

• WhatsApp Business: catalogue of services and prices; repair-day posts; before-and-after photos with permission.
• Google Business Profile: your workshop on the map, with "step-free entrance" stated.
• Signage: large, clear letters, readable from a seated position.
• Referrals: a referral slip that physiotherapists and disability groups can give users.
• Portfolio: a folder of job cards and photos (with permission) showing your work.
• Follow-up calls are marketing too: users remember the repairer who called to check.

Accessibility

Ghana's Persons with Disability Act 2006 (Act 715) required public buildings and services to become accessible within ten years, a period that ended in 2016, but disability groups say enforcement is weak. Make your own workshop an example: step-free entry, a seated bench, a clear turning space, picture price lists, and a phone and WhatsApp line for deaf users. Every Level 2 task can be done seated with the adjustments listed in Level 1; measuring a user and teaching transfers may need a standing or seated partner for the parts you cannot reach.

Check yourself

1. Name four parts you should keep in stock.
2. What is the Assemblies' disability fund now meant to support?
3. Why are follow-up calls also marketing?

1. Name the five body measurements and what each becomes.
2. In what order do you fit a chair?
3. Which users may you fit at Level 2, and whom must you refer?
4. Which spokes do you tighten to move the rim away from the pointer?
5. What are the truing limits for side-to-side and up-and-down?
6. Name three causes of castor flutter.
7. What do you do with a cracked frame?
8. Give WHO's example cushion and well sizes.
9. Describe the three pressure test levels.
10. When is a first follow-up often useful?
11. Where should an elbow crutch handle sit?
12. Name three partners for a wheelchair repair service.

Best next reads: WHO Wheelchair Service Training Package, Basic level (Reference Manual and Workbook); WHO Wheelchair provision guidelines (2023); Park Tool's wheel-truing pages; the Hub's Basic Welding and Money Skills Level 2 manuals.

What this module does not cover: postural support and fitting for users with complex needs (WHO Intermediate level, trained professionals only), frame welding, electric wheelchairs, and registering and running a full business (see Level 3).

Every source used in this manual is listed, with links, in the Teacher Copy.