Telehealth for complex wheelchair assessment: A scoping review protocol of implementation in low-resource settings

Abstract

Background

Access to specialist wheelchair assessment services remains limited globally, particularly in low- and middle-income countries (LMICs) where geographical barriers and limited specialist availability create challenges for users with complex needs. While telehealth approaches offer potential access solutions, existing evidence on telehealth wheelchair assessment predates recent technological advancements and the accelerated adoption following COVID-19.

Objective

This proposed study aims to map and synthesise current evidence on telehealth wheelchair assessment practices, including their description, implementation, effectiveness, and stakeholder experiences, with particular focus on implementation considerations relevant to low-resource settings.

Methods

This protocol outlines the planned methods for a scoping review following JBI methodology and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines. PubMed, Web of Science, EBSCOhost, Scopus, Cochrane Library, and grey literature will be searched for studies published in English or French from 2015–2025. The review will include studies involving any stakeholders participating in telehealth wheelchair seating assessments across any healthcare setting globally, with specific attention to LMICs. Studies will be excluded if they focus solely on technology development without wheelchair assessment application, remote wheelchair control without assessment components, or general telehealth applications not specific to wheelchair assessment. Two independent reviewers will conduct study selection, data extraction using a standardised tool, and thematic analysis. Results will be presented through narrative synthesis with descriptive tables and thematic organisation.

Conclusion

This review will map the scope and nature of current evidence on telehealth wheelchair assessment, identifying research gaps and areas requiring further investigation. Findings will provide insights into current practices, implementation approaches, and stakeholder perspectives to inform research priorities and guide the development of evidence-based telehealth wheelchair services in low-resource settings.

Scoping review registration

The protocol has been registered prospectively on Open Science Framework (OSF): https://osf.io/7ecq6.

Background

Access to assistive technologies (ATs), including wheelchairs, is fundamental to enabling mobility, participation, and overall well-being for individuals with mobility impairments.^1,2 More than 2.5 billion people globally require at least one assistive product, a figure projected to rise to 3.5 billion by 2050 ² Wheelchairs are among the most essential assistive products, and the need is substantial and growing: an estimated 80 million people (approximately 1% of the world's population) require a wheelchair. ³ Yet despite this need, access remains highly inequitable. In many settings, individuals either do not obtain a wheelchair at all or receive one without trained assessment or guidance, increasing the risk of inappropriate prescription and preventable complications. ³

For individuals with complex mobility needs, appropriate wheelchair seating is essential for maintaining posture, preventing pressure injuries and musculoskeletal deformities, optimising function, and supporting participation. Inadequate seating can lead to pain, compromised balance, postural asymmetry, and elevated risk of pressure injury – factors that significantly impair health and daily functioning. ⁴ Achieving optimal seating requires comprehensive assessment by clinicians with specialised expertise, including detailed client interviews, postural and physical evaluation, environmental assessment, and knowledge of seating and wheelchair configurations.^5–7 These demands are especially pronounced for users with complex needs, such as individuals with high cervical spinal cord injury, progressive neurological conditions, or paediatric users requiring customised and growth-accommodating seating. ⁸ However, advanced wheelchair and seating expertise is often concentrated in tertiary or specialist rehabilitation units, creating substantial access barriers for people in rural or underserved areas.^9,10

Access to the specialised rehabilitation services required for wheelchair and seating assessment is particularly limited in low- and middle-income countries (LMICs). Broader rehabilitation constraints – including major gaps in service availability, affordability, infrastructure, and workforce capacity – leave more than half of people with disabilities in LMICs with unmet rehabilitation needs.^11,12 These system-level pressures directly affect wheelchair and seating provision, which relies on trained rehabilitation personnel who remain in critically short supply across many LMIC health systems^7,13,14 For example, recent estimates from South Africa illustrate these shortages, with only 0.71–1.03 rehabilitation therapists per 10,000 uninsured population. ¹⁵ Weak governance structures, fragmented service pathways, insufficient or inconsistent AT funding, and limited workforce training in wheelchair provision further constrain access^7,9,13,16,17 Environmental and socioeconomic barriers – including inaccessible environments, travel distance, transportation challenges, and indirect costs – compound these limitations.^17,18 As a result, specialised wheelchair and seating services are often difficult to access in LMICs, contributing to delays, inappropriate prescriptions, and poorer participation outcomes for wheelchair users in underserved areas.^9,10,19

In this context of inequitable access, telehealth – defined as the remote delivery of healthcare services through telecommunications technologies – offers a potential strategy to extend the reach of specialist wheelchair and seating assessment services.^10,20,21 Early evidence suggest that tele-wheelchair assessment can achieve comparable measurement accuracy, satisfaction, and clinical outcomes to in-person assessment under certain conditions.^20,22 More recent reviews similarly indicate that telehealth approaches are feasible, can reduce travel burden, and may enhance access for rural users. ¹⁰ The COVID-19 pandemic accelerated telehealth adoption globally, to a large degree overcoming some previously identified implementation barriers and increasing acceptance among clinicians and service users. ²³ Furthermore, technological innovations are paving the way for more effective tele-wheelchair assessments. For example, pressure-mapping technology offers objective data on interface pressure and pressure redistribution – information that supports evidence-based seating surface decisions. ²⁴ When such tools are integrated within telehealth platforms, they may mitigate specific concerns raised by specialist assessors, particularly regarding measurement accuracy and fidelity of the remote assessment process.^10,25

However, successful implementation of tele-wheelchair assessment requires more than demonstration of clinical effectiveness. Research highlights the need for clear protocols, clinician training in tele-delivery methods, adequate connectivity and technological infrastructure, collaborative workflows between specialist and non-specialist providers, and culturally safe, user-centred practices that support autonomy and shared decision-making.^19,26,27 At present, substantial knowledge gaps remain in terms of how telehealth wheelchair assessments are being implemented, the range of technologies used, stakeholder perspectives, and context-specific enablers or barriers – particularly in low-resource settings. The most recent scoping review of telehealth for wheelchair assessment ¹⁰ included studies published up to 2011, predating major advances in telehealth technology, digital connectivity, and post-pandemic service transformation.

Given these knowledge gaps, an updated synthesis of the literature is needed to clarify current telehealth wheelchair assessment practices, technologies used, stakeholder experiences, and implementation considerations, particularly within low-resource settings. This protocol describes the methods for a planned scoping review, that will aim to map and describe the existing evidence base across these domains, with the intention to provide an overview of how tele-wheelchair assessment has been approached to date and identify areas where further investigation is needed.

Methods

This manuscript presents the protocol for a planned scoping review and is reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) ²⁸ guidelines (Appendix 1). The scoping review will be conducted using the Joanna Briggs Institute (JBI) methodology for scoping reviews ²⁹ and reported in accordance with the PRISMA-ScR guidelines. ²⁸ The review will employ a five-stage framework recommended by Arksey and O'Malley ³⁰ consisting of: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) data charting, and (5) collating, summarising and reporting of the study findings.

Step 1: Identifying the research question

The scoping review will aim to answer the following overarching research question: ‘What is known about telehealth wheelchair assessment practices, including their description, implementation, effectiveness, and stakeholder experiences, and what factors influence their successful integration into healthcare services, particularly in low- and middle-income countries?’

The sub-questions are as follows:

Scope and technologies: How is tele-wheelchair assessment described in the literature, and what technologies are used in remote seating assessments?

Outcomes and measurement: What outcomes from tele-wheelchair assessments have been examined, and how are these outcomes measured and evaluated?

Training: What training requirements/considerations, methods and/or models exist for conducting effective tele-wheelchair assessments?

Effectiveness: What evidence exists regarding the effectiveness of tele-wheelchair assessments compared to in-person wheelchair assessments, including according to stakeholder perceptions?

Stakeholder experiences: What are the experiences and perceptions (over and above effectiveness) of key stakeholders (including but not limited to wheelchair users, specialist and non-specialist assessors, service managers, and funders) with tele-wheelchair assessments?

Implementation considerations: What implementation factors and frameworks have been used for successful tele-wheelchair assessment integration into practice (with specific inquiry into contextual factors including cultural considerations, participatory approaches etc.)?

Implementation considerations specific to low-resource settings: What practical strategies for implementing tele-wheelchair assessment have been identified in low-resource and LMIC contexts, including adaptations for infrastructural limitations, low-cost technology solutions, culturally responsive practices, and locally driven capacity building?

Step 2: Identifying relevant studies

The review will incorporate both published and grey literature. A three-step approach will be used for the search strategy. Initially, a preliminary search will be done on PubMed to identify any relevant publications on this topic. Text words and index terms in the titles and abstracts of these publications will be examined and noted. Insights from this phase will assist in informing the developing of a comprehensive search strategy. Finally, the refined search strategy and identified keywords from the tiles and abstracts will be adapted for each database and information source.

The following databases will be searched: PubMed, Web of Science, EBSCOhost (including Africa Search Premier, Africa-Wide Information, CINAHL, eBook Collection, E-Journals, Masterfile Premier, MEDLINE, Health Source: Nursing/Academic Edition), Scopus, and the Cochrane Library. The following databases and repositories will be used to search for unpublished publications and relevant grey literature: Google Scholar, NDLTD Global Electronic Thesis and Dissertation, OpenDOAR, CORE, National ETD, OATD, IRSpace (which specifically searches South African Institutional Repositories) and relevant organisational websites (e.g. World Health Organization).

The search will cover English and French papers published from 2015 to 2025, to capture any new and recent developments in this field since the previous scoping review published in 2020. ¹⁰ Reference lists from eligible studies will undergo screening to identify additional pertinent literature. Key search terms will comprise of telehealth, telemedicine, telerehabilitation, wheelchair, seating, remote assessment, virtual assessment, AT, and remote consultation. The search strategy for PubMed is provided in Appendix 2.

Step 3: Study selection

Eligibility criteria

The population, concept and context framework elements that guided the development of this review are summarised in Table 1.

Table 1.

Population, concept, and context (PCC) framework elements for the scoping review of telehealth wheelchair seating assessments.

PCC element	Inclusion criteria	Primary focus	Exclusion criteria
Population	Wheelchair users, specialist/non-specialist assessors, service managers, funders, caregivers, technicians	All stakeholder perspectives	None
Concept	Remote wheelchair seating assessment via telecommunications	Procedures, technologies, effectiveness (quantitative and/ or qualitative), training, implementation factors	Technology development only; remote control; tissue healing; non-wheelchair telehealth
Context	All settings where telehealth wheelchair assessment delivered within healthcare services context	LMIC findings emphasis	Initiatives that provide wheelchairs through non-clinical/unregulated distribution models

LMIC: low- and middle-income country

Population

The review will include literature involving any stakeholders participating in telehealth wheelchair seating assessments. These may include wheelchair users (adults and children) receiving remote assessment, specialist assessors (occupational therapists, physiotherapists, or other healthcare professionals with training in wheelchair prescription), non-specialist assessors (healthcare professionals who assist in the assessment process without specialised training), service managers overseeing telehealth wheelchair assessment services, funders of wheelchair provision programmes, family members or caregivers of wheelchair users, and wheelchair technicians involved in the assessment or provision process. Given the limited availability of specialist seating clinicians in many LMIC settings, telehealth assessment models frequently rely on collaboration between specialist and non-specialist providers^7,10; therefore, all clinician groups involved in remote seating assessments will be included, with roles differentiated during data extraction to support appropriate interpretation. No exclusion criteria based on participant characteristics such as age, gender/sex, health condition, or geographic location will be applied.

Concept

The review will include publications addressing wheelchair seating assessments conducted via telehealth technologies. For the purposes of this review, telehealth wheelchair assessment (tele-wheelchair) is defined as remote assessment of wheelchair and seating requirements using telecommunications platforms, facilitating evaluation when the assessor and user are geographically separated. ‘Healthcare services’, for this review, are defined in accordance with the World Health Organization as ‘all services dealing with the promotion, maintenance and restoration of health… [including] … both personal and population-based health services’. ³¹ Within this review, this includes regulated public, private, and not-for-profit service structures where trained health personnel provide clinical, rehabilitation, or assistive-technology assessment activities. Key aspects of the concept to be explored include description of telehealth wheelchair assessment procedures and protocols, technologies used for remote assessment (videoconferencing, specialised measurement tools, mobile applications, etc.), outcomes measured and methods of evaluation, training requirements for conducting effective telehealth assessments, evidence of effectiveness compared to in-person assessments, implementation factors, barriers, and facilitators, technology integration approaches, and implementation frameworks or models used. The review will exclude initiatives that provide wheelchairs through non-clinical or unregulated distribution models (e.g. donation programmes or ad hoc humanitarian supply efforts without a structured clinical assessment component). Humanitarian organisations that deliver regulated rehabilitation or wheelchair assessment services staffed by trained personnel remain eligible for inclusion. Studies in which telehealth or telerehabilitation is mentioned only tangentially or not evaluated as a meaningful component of the wheelchair assessment process (e.g. mixed models where remote elements are not described or analysed) will be excluded. Additional exclusion criteria will be studies that solely investigate technology development without application to wheelchair assessment, remote control of wheelchairs without assessment component, tissue healing monitoring in isolation from comprehensive wheelchair evaluation, or general telehealth applications not specific to wheelchair assessment.

Context

This scoping review will include studies from all settings where telehealth wheelchair assessment is delivered, although papers from LMICs will be a specific focus when describing findings. This may include hospital-based services, community-based rehabilitation programmes, private practice settings, rural and remote healthcare services, home-based assessments, international and humanitarian contexts, and any geographic location globally. The review will focus on factors related to barriers and facilitators, technology integration, training approaches, and implementation protocols.

Types of sources

All quantitative and qualitative research methodologies will be eligible for inclusion. This encompasses controlled trials, observational studies, case studies, and qualitative investigations using various theoretical frameworks. Review articles and synthesis studies will also be considered. Text and opinion papers (editorials, expert opinions, organisational reports) and grey literature (theses, dissertations, organisational guidelines) will also be included.

Selection process

All search results will be gathered and transferred to Rayyan (Review Management Platform) ³² where duplicate entries will be eliminated. A pilot test using the eligibility criteria will be done on 20 titles and abstracts and duplicates removed. Following pilot validation, independent screening of titles and abstracts will be conducted by two reviewers applying the inclusion criteria. Full-text articles of interest will be accessed and their reference details uploaded to EndNote v21.5 (Clarivate Analytics, PA, USA). Two independent reviewers will conduct detailed evaluation of all full-text articles against the inclusion criteria. Exclusion decisions and their justifications will be systematically recorded for reporting purposes. Discrepancies between reviewers will be resolved via collaborative discussion or involvement of supplementary reviewers. The complete search methodology and study selection workflow will be documented and presented via a PRISMA-ScR flow diagram in the final publication. ²⁸

Reviewer selection and expertise

The review team will be constituted to ensure appropriate methodological and clinical expertise. Database searching and deduplication will be conducted by a physiotherapist trained and experienced in evidence searching and scoping review methodology (GP). Title, abstract and full-text screening will be completed independently by KB and TC; KB is a physiotherapist and researcher with experience in (tele)rehabilitation and AT, and TC is a physiotherapist with extensive clinical experience in wheelchair and seating assessment. Data extraction and synthesis will be undertaken by KB, TC and EN. EN is a physiotherapist researcher with experience in disability, telerehabilitation, and evidence synthesis methods. Any discrepancies will be resolved through consultation with QL, who has a background in physiotherapy and extensive expertise in evidence synthesis, rehabilitation systems research and AT in LMIC contexts.

Step 4: Charting the data

All included publications will be uploaded to Atlas.ti v25 for data management and analysis. Data extraction will be performed independently by two reviewers using a standardised extraction template developed in Microsoft Excel and applied within the Atlas.ti platform. Data collection will focus on participant demographics, key concepts, contextual elements, study design features, and relevant outcomes. The following categories will be documented:

Study characteristics (author, year, country and World Bank classification, study design, aims/purpose)

Participant characteristics (type of stakeholders, sample size, demographics, clinical characteristics if relevant)

Description of telehealth wheelchair assessment (technologies used, assessment protocols)

Outcomes measured and evaluation methods

Training requirements, methods and/or models described

Evidence of effectiveness compared to in-person assessment

Stakeholder experiences and perceptions

Implementation factors of tele-wheelchair seating assessment (e.g. frameworks, strategies, readiness, contextual facilitators/barriers)

Barriers and facilitators of the implementation of the tele-wheelchair seating assessment.

Technology integration approaches

Implementation frameworks or models used

Key findings relevant to the review questions

These extraction fields are mapped to the review sub-questions to ensure that all data relevant to answering the research objectives are systematically captured. The preliminary draft of the data extraction form is presented in Appendix 3. The draft extraction form will be piloted on three randomly selected documents (including one grey literature source) to ensure comprehensiveness and usability, and refined as needed. Additionally, the form will continue to undergo refinement during the extraction phase to accommodate the characteristics of included studies and grey literature. All modifications to the form will be systematically recorded and reported in the final review. Disagreements will be resolved through reviewer discussion or additional reviewer input. Study authors will be approached to supply missing or supplementary data when necessary.

Step 5: Collating, summarising, and reporting the results

If sufficient qualitative data are identified, a reflexive thematic analysis will be conducted following Braun and Clarke's approach,^33,34 integrating both inductive and deductive elements. ³⁵ Two reviewers will independently code qualitative data, iteratively developing and refining themes through discussion and consensus. All coded material will be organised in a Microsoft Excel spreadsheet and mapped to the emerging thematic structure. Quantitative findings (e.g. measurement reliability, clinical outcomes) and descriptive implementation information will be summarised narratively and integrated within the overarching thematic or topic framework. These data will be synthesised in relation to each of the seven review questions, describing the extent, nature, and consistency of available evidence and identifying key gaps (e.g. under-represented settings, populations, or implementation components).

Findings will be reported in three formats: (1) A PRISMA-ScR flowchart showing the study selection process, (2) tables summarising study characteristics and evidence mapped to themes, and (3) a narrative synthesis organised around the themes and sub-questions.

Discussion

The proposed scoping review will endeavour to address current knowledge gaps in telehealth wheelchair assessment, particularly for LMIC contexts where access barriers are most pronounced. By updating the evidence base since Graham et al.'s ¹⁰ previous review, this study will aim to capture technological advances and the accelerated telehealth adoption following the COVID-19 pandemic, with the intention of summarising how tele-wheelchair assessment approaches have been described in recent literature.

The focus on implementation considerations relevant to LMICs is envisaged to highlight factors that may be useful when considering service adaptation in resource-constrained settings. Identification of barriers, facilitators, and implementation factors may help clarify considerations relevant to developing contextually appropriate service delivery models. This is particularly important given existing evidence gaps in standardised protocols for telehealth wheelchair assessment. Furthermore, by synthesising stakeholder experiences and perceptions, the review may highlight considerations relevant to person-centred approaches that support wheelchair user autonomy and choice. Such insights may contribute to a broader understanding of factors influencing telehealth intervention acceptability and sustainability.

Beyond videoconferencing, several objective measurement technologies have been trialled alongside remote assessments or monitoring of wheelchair seating or use. The planned review will examine such technologies, as understanding how they have been integrated within telehealth platforms may offer insight into factors relevant to protocol development and considerations related to assessment fidelity. ¹⁰ Examples include seat- and pressure-sensor systems used to monitor pressure relief and activity, ³⁶ real-time pressure-mapping feedback pilots, ³⁷ and (albeit not necessarily studied alongside remote assessment) markerless motion-capture approaches designed to quantify wheelchair-related postural or kinematic variables in clinical and community environments.^38,39 The proposed benefits of these technologies include that they may provide structured quantitative data – such as pressure distribution, postural angles, or movement characteristics – that could complement visual clinical judgement, along with live feedback on body position or pressure potentially improving user awareness.^37,40 However, the previous scoping review highlighted that the integration of additional technologies in telerehabilitation for wheelchair seating remains minimally studied, with mostly pilot work available and a need for further research. ¹⁰ The planned scoping review will map how these technologies have been applied, what evidence exists regarding their measurement properties or feasibility, and what contextual constraints or enablers have been reported.

Potential limitations

A potential limitation of the forthcoming scoping review is the variability in terminology used to describe telehealth interventions, wheelchair services, and AT assessment processes, which may result in some relevant studies not being captured despite a broad search strategy. Although efforts will be made to search across multiple databases and include grey literature, publication bias remains possible, as studies reporting positive or feasibility-supporting outcomes may be more likely to appear in the published literature than studies reporting neutral or negative findings. Another limitation is the geographical imbalance in available research. While LMIC-specific evidence is known to be scarce, research output may also vary substantially across high-income regions, potentially influencing the distribution and representativeness of included studies. These patterns will be acknowledged when interpreting the breadth and generalisability of the mapped evidence. Finally, consistent with current scoping review guidance,^29,41 the review will not include formal quality appraisal, as this would not meaningfully advance its objective of mapping and describing a broad and mixed body of evidence. Instead, we will extract and report key methodological characteristics and author-reported limitations to support transparent interpretation of the findings.

Conclusion

This protocol describes the planned approach for systematically mapping the existing evidence on telehealth wheelchair and seating assessment, including descriptions of assessment practices, technologies used, outcomes examined, stakeholder experiences, and implementation considerations, with particular attention to low-resource and LMIC contexts. The review aims to provide an organised overview of what is currently known across these domains and to identify areas where evidence is limited or underdeveloped. By clarifying the scope, characteristics, and gaps in the literature, the planned review is intended to inform future research priorities and support ongoing discussions related to service development and policy.