Exercise guide
Exercise is safe and worth doing when you use a wheelchair, and you can start at home with a resistance band. Most of the research comes from people with a spinal cord injury, so this guide is built on that, but its advice on how much to do, looking after your shoulders and staying safe applies to most people who exercise sitting down, whatever the reason you use a wheelchair.
The short version: aim for at least 20 minutes of seated cardio twice a week and strength exercises twice a week, building to 30 minutes of cardio 3 times a week. Make shoulder exercises a regular part of it, because your shoulders do the work of walking. If your injury is at the sixth thoracic level (T6) or above, know the signs of autonomic dysreflexia.
This guide gives you the guidelines, the shoulder programme from the trials, seated moves with 3D demos, a follow-along workout, and the warning signs.
UK guidance found no evidence that appropriate activity is a risk for disabled adults, and says the myth that activity is harmful for disabled people should be dispelled. The World Health Organization (WHO) found no major risks when activity suits your current level, health and function, and the benefits outweigh the risks.
For fitness and strength: at least 20 minutes of moderate to vigorous aerobic exercise twice a week, plus 3 sets of strength exercises for each major muscle group you can use, twice a week. For heart and metabolic health: at least 30 minutes of aerobic exercise 3 times a week. Canada's version calls these the starting and advanced levels.
Between 30% and 73% of people with a spinal cord injury have shoulder pain, because the arms do the work of walking. In a randomised trial of 80 people with paraplegia and long-standing shoulder pain, a 12-week home programme of shoulder strengthening and stretching, with advice on transfers and pushing, cut pain to about a third of where it started.
An arm bike, a hand bike, wheeling, swimming and dancing all count as aerobic exercise. Arm cranking improved fitness after spinal cord injury in 18 studies, and small studies haven't found that it raises the risk of shoulder pain.
If your injury is at T6 or above, a pounding headache, flushing or sweating above your injury, or a stuffy nose can mean your blood pressure is dangerously high. Sit up, loosen anything tight, check your bladder, bowel and skin, and call 999 (911 in the US) if you can't find the cause or the symptoms don't settle.
Shift your weight regularly, check your skin, and don't exercise on a mark or sore over a pressure area. With a high injury you may not sweat below it, so exercise somewhere cool, with a fan, a water spray and cold drinks.
People use wheelchairs because of a spinal cord injury, multiple sclerosis (MS), cerebral palsy, an amputation, a stroke and many other conditions, and some walk short distances and use a chair for longer ones. In the UK, disabled adults are almost twice as likely as non-disabled adults to be physically inactive (39.3% compared with 19.7%), and 79% say their impairment or condition stops them being as active as they'd like.
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Damage to the spinal cord, from a fall, a road accident, violence or sport, or from causes such as a tumour, an infection or a problem with the blood supply. It can cause a complete or partial loss of movement and feeling below the injury. In paraplegia the legs are affected and the arms work; in tetraplegia the arms are affected too. About 15.4 million people worldwide live with a spinal cord injury, and in the UK someone has one every 2 hours, about 4,700 a year.
With paralysed legs, aerobic exercise uses the smaller muscles of the arms, which limits how hard you can work. People with a spinal cord injury have been described as being at the lowest end of the human fitness range, and about half of those in the US report no leisure-time activity. Fitness is lowest with tetraplegia, but it can still be trained.
With an injury at T6 or above, resting blood pressure is often low (a top number of 90 to 110, or 80 to 90 with a neck injury), your heart rate can't rise as high as usual, and your blood pressure can fall when you sit up. In one study this fall happened in half of people with a neck injury and 18% with an injury lower down, often without symptoms.
With an injury at T6 or above, something painful or irritating below the injury, most often a full bladder, can set off a sudden, dangerous rise in blood pressure: more than 20 points above your usual top number. The Spinal Injuries Association says it should always be treated as a medical emergency. It is about 3 times as common after a complete neck injury as after an incomplete one, but it can happen with incomplete injuries too, sometimes with milder symptoms.
Below a high injury you may not sweat or shiver normally, so you can overheat during exercise or get cold more easily.
Reduced feeling and long hours sitting raise the risk of pressure ulcers over bony areas such as the tailbone, hips, heels and elbows. Bone is lost quickly below a spinal cord injury, so a leg can break in a minor fall.
Pushing a manual chair, transfers and pressure-relief lifts make your arms do the work of legs: during a transfer, the pressure inside the shoulder joint is about 2.5 times what it is when the arm isn't bearing weight. Shoulder pain affects 30% to 73% of people with a spinal cord injury, and carpal tunnel syndrome 40% to 66%.
Problems with blood sugar, cholesterol, blood pressure and body fat that raise heart risk (cardiometabolic syndrome) affect 31% to 72% of adults with a spinal cord injury, depending on how they're defined, and body mass index (BMI) underestimates body fat after an injury. In a Canadian survey of over 60,000 people, those with a spinal cord injury had 2.7 times the odds of heart disease and 3.7 times the odds of stroke.
The level of your injury, and whether it's complete, shape what exercise looks like more than anything else. In a Swiss survey of 1,549 people, shoulder pain was more likely in women (1.89 times the odds), with tetraplegia or complete paraplegia, and with spasticity or contractures; the primary care guide adds higher weight and older age. These are patterns, not reasons to train differently. Women with an injury at T6 or above have a higher risk of severe dysreflexia in pregnancy, labour and breastfeeding, and should be looked after by a specialist team. Adults over 65 were almost absent from the trials behind the guidelines.
The 2018 international guidelines rest on a review of 211 studies, 189 of them in people injured more than a year earlier. Confidence was moderate to high that exercise improves fitness, power, strength, body composition and heart risk markers. In the first year after injury the evidence was very low, and bone health didn't improve. Side effects were rare apart from occasional muscle or joint pain.
34 people with spinal cord injuries from the neck to the lower back were randomised to 9 months of arm cranking and strength training twice a week, or to carry on as usual. The exercise group's arm-cranking power rose by 81% and their upper-body strength by 19% to 34%, and they reported less pain, stress and depression and better quality of life. They came to 82.5% of sessions.
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In 19 trials (797 adults under 65), exercise improved wellbeing and quality of life by small to moderate amounts, but the certainty was low, and 4 serious side effects were probably linked to the exercise. In 21 earlier studies, more active people reported better wellbeing and fewer symptoms of depression.
In 18 studies (235 people), arm cranking for 30 to 40 minutes, 3 to 5 times a week improved fitness (moderate certainty); its effects on body fat, heart risk and quality of life were very uncertain. Small studies haven't found that it raises the risk of shoulder pain or other injuries. A review of 7 randomised trials found the results inconsistent but judged it suitable and safe.
In 4 trials (167 manual wheelchair users with a spinal cord injury), exercise with a physiotherapist reduced shoulder pain by 19 points on a 150-point scale and improved function. In 7 studies, arm cranking, strengthening and stretching each reduced pain by more than the smallest change the scale can detect. The trials are few and small.
In the STOMPS trial (strengthening and optimal movements for painful shoulders), 80 people with paraplegia and long-standing shoulder pain were randomised to a 12-week home programme of shoulder strengthening and stretching, with advice on transfers, pressure-relief lifts and pushing, or to an education video. Pain fell to about a third of where it started in the exercise group and didn't change with the video, and strength and quality of life improved. Many people dropped out, and people with tetraplegia weren't included. Stronger muscles that turn the arm outwards explained much of the gain.
The same programme was taught to 100 manual wheelchair users with paraplegia who had no shoulder pain. New shoulder pain appeared in 11% after 18 months and 24% after 3 years, compared with 27% and 40% in an earlier group of patients who weren't taught it. That comparison wasn't randomised, so the real effect may be smaller. People who did the exercises about 3 times a week in the first 4 months were more likely to stay free of pain than those who did them about twice.
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In 223 people with paraplegia followed for 3 years, being more active didn't predict new shoulder pain. People who developed pain had been 10% to 15% weaker beforehand, especially in the muscles that pull the arm in, and less active. The upper limb guideline says its advice to cut down repetitive tasks shouldn't be taken as advice to do less activity overall.
Bone is lost quickly below the injury. In 11 trials of electrical stimulation with exercise, standing, vibration and other treatments, only 3 showed a benefit to bone density, and most had some risk of bias. The 2018 guidelines found too little evidence on bone, and medicines and fracture prediction after a spinal cord injury have limited evidence too. Ask your spinal centre about bone health rather than relying on exercise.
Cycling driven by electrical stimulation of the leg muscles (functional electrical stimulation, or FES, cycling) improved the health of the leg muscles in 92 studies (999 people, high certainty) and may improve power and fitness (low certainty). It needs specialist equipment and wasn't part of the 2018 guidelines, because there weren't enough high-quality trials.
A spinal cord medicine guideline recommends at least 150 minutes of exercise a week, as you're able, from as soon as possible after injury. Its evidence is low level, and critics say parts of it are borrowed from research in people without a spinal cord injury. The international guideline's 30 minutes 3 times a week is the smallest amount shown to help, not the most you can do.
Starting level, for fitness and strength: at least 20 minutes of moderate to vigorous aerobic exercise twice a week, and 3 sets of 10 of strength exercises for each major muscle group you can use, twice a week. Advanced level, which adds heart and metabolic benefits: 30 minutes of aerobic exercise 3 times a week, with the same strength work. They're for adults aged 18 to 64 more than a year after injury; check with a health professional first if your injury is recent, you're older, or you have other conditions.
UK and WHO guidance for disabled adults is the same as for everyone: build towards 150 minutes of moderate activity a week, with strength (and balance where you can) on at least 2 days, and don't stay still for too long. Wheeling your wheelchair counts as strengthening activity, and even a little movement is better than nothing.
The trials used 3 sets of 10 at a moderate to hard effort. Active Homes, a home guide for people with paraplegia, starts at 3 sets of 8 to 10 of each exercise, at least twice a week but not 3 days in a row, and moves from 3 sets of 8 to 3 sets of 10, then to a heavier band or weight. The upper limb guideline starts more gently, with 1 set of 8 to 12 reps, 2 to 3 days a week.
Moderate means you can talk but not sing; vigorous means you can't say more than a few words without pausing. With an injury at T6 or above your heart rate rises less than usual, so don't chase heart-rate targets. Rating your effort on a 6 to 20 scale has some support, though the evidence is weak.
Two days: 20 minutes of seated cardio at a talk-but-not-sing effort. Two or three days, not in a row: the wheelchair workout below, with its shoulder exercises. Every day: shift your weight, check your skin, and break up long spells of sitting still. After 4 to 8 weeks, build the cardio to 30 minutes, 3 times a week.
Shoulder pain after a spinal cord injury is mostly overuse of the rotator cuff, the muscles that hold the shoulder joint together. It comes from taking weight on your arms in transfers and pressure-relief lifts, from pushing, and from reaching up from a seated position. Up to 72% of people develop it within 20 years of injury. Because your shoulders do the work of walking, they're worth protecting from the start.
Four strengthening exercises with a band and a light weight: rows that draw your shoulder blades back (3 sets of 15); turning the arm outwards with your elbow at your side (3 sets of 8); pull-downs from no higher than shoulder height (3 sets of 8); and raising your arms a little forward of sideways to shoulder height, thumbs up (3 sets of 15). Plus 3 stretches: the front of the shoulder, the back of the shoulder and the top of the shoulder (the upper trapezius).
3 days a week, with a rest day between. At first, set the reps and resistance so they don't hurt; after 2 to 4 weeks, use loads you can only just manage for the set (8 or 15 reps), and keep increasing the resistance. The primary care guide also recommends regular checks with a physiotherapist, even without pain.
Push with long, smooth strokes, and let your hand drift down below the rim on the way back. Transfer between surfaces of the same height where you can, grip the edge rather than putting your palm flat, vary which arm leads, and consider a transfer board. Keep your hands below shoulder height for everyday tasks: use a reacher and lower shelves.
The lightest fully adjustable chair you can get, with the rear axle as far forward as is stable, your elbow bent to 100 to 120 degrees when your hand is at the top of the rim, and tyres kept pumped up. Power assistance or a power chair can help if you're at high risk or already have pain.
Leave out dips and other exercises that take your weight on your arms until the muscles that pull the arm down are strong. Keep overhead presses for later, and leave them out if your shoulder hurts or has been injured. For pressure relief, lean forwards or to the side rather than relying on push-up lifts.
Our shoulder pain guides allow some discomfort during strengthening. Spinal cord injury guidance is stricter: it says to avoid strengthening exercises that are painful, and to treat pain as early as possible so it doesn't become long-term. Choose loads that don't hurt, and ask a physiotherapist to check your shoulder, your transfers and how you push.
3 days a week with a rest day between: rows 3 sets of 15, turning out and pull-downs 3 sets of 8, raises to shoulder height 3 sets of 15 (the STOMPS programme), then the three stretches for 30 seconds each side. Sit with your brakes on; most demos are standing, and the pull-down has no demo yet.
3D demoBand rowBeginner · A band + An anchor point
3D demoStanding band external rotationBeginner · A band + An anchor point
Seated band pull-down (from shoulder height)Beginner · A band + An anchor point + A bench or box
3D demoScaption raiseBeginner · A dumbbell
3D demoDoorway chest openerBeginner · A wall
3D demoCross-body shoulder stretchBeginner · No equipment
3D demoUpper trap releaseBeginner · No equipmentArm cranking is the most common aerobic exercise people with a spinal cord injury do outside hospital, and it's one of the exercises that reduced shoulder pain in wheelchair users. Gyms and rehabilitation units often have an arm bike, and a hand bike takes it outdoors.
The Canadian guidelines list wheeling, swimming, hand cycling and dancing as aerobic exercise, and UK guidance counts wheeling as strengthening activity too.
Punching forwards at chest height, as in the seated MS workout, raises your heart rate with the arms only. It hasn't been tested in trials: it's our suggestion for days without an arm bike.
Start with 10 to 20 minutes twice a week, in 3-minute bouts with an easy minute between (our editorial starting point). Build to 20 minutes of moderate to vigorous effort twice a week, then 30 minutes 3 times a week.
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Work at a talk-but-not-sing effort. The arm crank has no 3D demo yet: follow its written steps. Leg cycling only suits people whose legs work, for example with MS or an incomplete injury.
Strength: 3 sets of 8 to 10, at least twice a week but not 3 days in a row (Active Homes). Stretches: 15 to 30 seconds, at least 2 to 3 times a week. Carpal tunnel syndrome is common, so look after your wrists, and skip the wrist flexor stretch if your grip is weak.
3D demoBand pull-apartIntermediate · A band
3D demoStanding band reverse flyBeginner · A band + An anchor point
3D demoSeated dumbbell curlBeginner · A dumbbell + A bench or box
3D demoLat pulldownBeginner · A cable machine
3D demoSide neck stretchBeginner · No equipment
3D demoWrist & forearm flowBeginner · No equipment
3D demoWrist extensor stretch (tennis elbow stretch)Beginner · No equipment
3D demoTendon glides (hand tendon gliding exercises)Beginner · No equipmentWhat you can do depends on your injury: Active Homes says to do weighted trunk twists only if you have control of your abdominal muscles. Holding a light weight at chest level turns the rotation into a trunk twist (3 sets of 8 to 10). The dead bug is done on a bed or mat.
Empty your bladder (and bowel, if that's part of your routine), check your catheter isn't kinked and the bag isn't full, and make sure straps, clothing and shoes aren't tight. Put your brakes on, anchor bands securely, and drink if you sweat.
If your injury is at T6 or above, stop if you get any of the signs below. Stay sitting up, or sit up and lower your legs, loosen anything tight, and look for the cause: your bladder first, then your bowel, then your skin. Call 999 if you can't find it or the symptoms don't settle.
Carry an emergency card that explains dysreflexia (free from the Spinal Injuries Association), know your usual blood pressure, and never set dysreflexia off on purpose to perform better (boosting): it can cause a dangerous, uncontrollable rise in blood pressure.
If you feel light-headed, faint or unusually tired, stop, tilt back or recline, and wait. Compression stockings, an abdominal binder, enough to drink and slow changes of position can help. Low blood pressure and dysreflexia can feel alike, so check your blood pressure if you're unsure; it can also drop after dysreflexia medicine.
Avoid exercising in the heat, use a fan, a water spray and cold drinks, wear light clothing, and stop to cool down if you feel too hot, dizzy or unwell. In the cold, wear layers and have warm drinks, and take care with heaters on skin you can't feel.
Don't do exercise that rubs or presses on a mark or sore over a pressure area, and check your skin after using new equipment or seats. Spinal cord injury guidance suggests shifting your weight every 10 to 15 minutes if pressure is a concern, and NICE (the National Institute for Health and Care Excellence) suggests a high-specification foam cushion if you use a wheelchair.
With thin bones in your legs, move carefully on and off equipment. Get any swelling, redness or change of shape in a leg checked, because you may not feel a broken bone, and a fracture can set off dysreflexia.
Check bands for nicks and tug-test the anchor first. If your grip is weak, wrap the band firmly, but not too tightly, around your hands. Wash or sanitise your hands after wheeling and before eating.
Start with the wheelchair workout, 3 times a week. The seated MS workout adds cardio intervals (leave out its overhead press if you push a manual wheelchair). The shoulder routine's rotator cuff and shoulder-blade blocks can be done seated; skip the moves that take your hands overhead or onto the floor.
A 30-minute workout in your wheelchair: a warm-up, seated cardio, four shoulder exercises from a trial programme, and stretches for the front of the shoulders.
30 minBeginner14 movesA bench or box, A bandA 25-minute workout done sitting, in a chair or wheelchair: seated cardio intervals, light strength work, posture and stretches, with pacing and cooling built in.
25 minBeginner14 movesA bench or box, A dumbbellA 25-minute band routine for healthy shoulders: move the shoulder and upper back through their range, then strengthen the rotator cuff and shoulder blades.
25 minBeginner12 movesA wall, A bandEight gentle neck and shoulder stretches for desk stiffness, done standing or seated in ten minutes.
10 minBeginner8 movesA wallThe shoulder, skin and temperature advice applies widely, and the UK and WHO guidance covers all disabled adults, but the amounts above come from spinal cord injury trials. ME/CFS (myalgic encephalomyelitis or chronic fatigue syndrome) and PoTS (postural tachycardia syndrome) follow different advice, built around energy and posture. For conditions without a guide here, such as muscular dystrophy or motor neurone disease, ask your specialist team.
MS exercises from NICE and the MS Trust: how exercise helps fatigue, walking and mood, why it doesn't trigger relapses, keeping cool, and seated options.
Cerebral palsyCerebral palsy exercises for children and adults from NICE guidance and trials: strength training, fitness, stretching (honestly), falls, fatigue and sport.
AmputationExercise after a leg or arm amputation, from NHS and physiotherapy guidance: strength, balance, fitness, stump care, phantom pain and falls, with 3D demos.
StrokeExercises after a stroke for when you're home from hospital: walking, strength and balance moves, fatigue, blood pressure and the FAST signs to call 999.
Older adultsExercises for seniors from WHO and NHS guidance and falls trials: how much you need, balance and chair exercises, getting up off the floor, and when to stop.
ME/CFSExercise with ME/CFS: why NICE advises against graded exercise therapy, how to check for post-exertional malaise, and how to pace and move safely.
PoTSExercise for PoTS: start lying down, then build up. The Levine and CHOP programmes and their evidence, salt, fluids, compression and the warning signs.
WheelPower lists wheelchair sports from archery and athletics to hand cycling, gym and fitness, and para ice hockey. It runs sports festivals for people with a physical disability aged 5 and over, and free online exercise, yoga and boxing-fitness classes.
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Every Body Moves, from the British Paralympic Association, helps you find inclusive activities and home workouts. Activity Alliance is the national charity for disabled people in sport and activity.
Talk to your GP if low mood is affecting your life. In a crisis, call Samaritans on 116 123 or text SHOUT to 85258, and call 999 if you've seriously harmed yourself or feel you might. In the US, call or text 988.
The Spinal Injuries Association's support line is 0800 980 0501.
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UK guidance found no evidence that appropriate activity is a risk for disabled adults and says this myth should be dispelled. The WHO found no major risks when activity suits your level, health and function. The precautions that matter (dysreflexia, temperature, skin and shoulders) are specific and manageable.
In 223 manual wheelchair users followed for 3 years, being more active didn't predict new shoulder pain; being weaker did. The upper limb guideline says cutting down repetitive tasks isn't advice to do less activity, and small studies haven't found that arm cranking raises the risk of shoulder pain. What matters is how you push, transfer and reach, and keeping the shoulder muscles strong.
Wheeling counts as activity and as strengthening work. But the benefits in the spinal cord injury guidelines come from planned sessions of at least 20 to 30 minutes at a moderate to vigorous effort, plus strength training, and people with a spinal cord injury are among the least fit people there are.
The spinal cord injury fitness guideline's minimum is 20 minutes of aerobic exercise twice a week plus strength training twice a week, chosen because it's the smallest amount shown to work. UK guidance says even a little movement is better than nothing.
Only 3 of 11 trials of electrical stimulation, standing or vibration showed a benefit to bone density, and the 2018 guidelines found the evidence on bone insufficient. Exercise is for your heart, muscles, shoulders and mood; ask your spinal team about bone health.
Setting off dysreflexia on purpose (boosting) is dangerous: the autonomic dysfunction guideline warns it can cause uncontrollable, life-threatening rises in blood pressure.
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With an injury at T6 or above, your maximum heart rate is lower and your heart rate rises less, so heart-rate zones can mislead. Use the talk test, or rate your effort.
If you have a spinal cord injury, aim for at least 20 minutes of moderate to vigorous aerobic exercise twice a week, plus strength exercises for each muscle group you can use twice a week. For heart and metabolic health, build to 30 minutes of aerobic exercise 3 times a week. UK and WHO guidance for all disabled adults is to build towards 150 minutes a week, with strength on 2 days, as you're able.
A mix of seated cardio, such as an arm bike, hand bike, wheeling or swimming, and strength training, with extra work for the muscles at the back of the shoulders. Rows, turning the arm outwards with a band, pull-downs from shoulder height and light raises to shoulder height are the four exercises of the STOMPS shoulder programme.
Strengthen the muscles that pull the arm down and back and turn it outwards, stretch the front of your chest, and keep your hands below shoulder height for everyday tasks. Push with long, smooth strokes, transfer between surfaces of the same height, and grip rather than putting your palm flat. Get shoulder pain checked early.
Yes, with precautions. Empty your bladder first, check nothing is tight, keep cool, and know the signs of autonomic dysreflexia. Your heart rate may not rise much, so judge your effort with the talk test.
It's a sudden, dangerous rise in blood pressure in people with an injury at T6 or above, set off by something below the injury, most often a full bladder. Sit up and lower your legs, loosen anything tight, look for the cause (bladder, then bowel, then skin), and call 999 if you can't find it or it doesn't settle.
Arm cranking on an arm bike, hand cycling, wheeling, swimming and dancing all count, and seated boxing is another option. Arm cranking improves fitness, and small studies haven't found that it raises the risk of shoulder pain.
Yes. In the trials behind the spinal cord injury guidelines, 3 sets of 10 at a moderate to hard effort twice a week built strength, and a 9-month programme raised upper-body strength by 19% to 34%. Bands, dumbbells or filled water bottles work at home.
Exercise improves body composition after a spinal cord injury, though for arm cranking on its own the evidence on body fat is very uncertain. Body mass index underestimates body fat after a spinal cord injury, so ask your team how best to track your weight and heart health.
Ordinary exercise can't be relied on to protect the bones of paralysed legs. Cycling driven by electrical stimulation of the leg muscles (FES cycling) improves the health of those muscles; ask your spinal centre whether it suits you.
Shift your weight regularly, use a good cushion, check your skin after exercise and after using new equipment, and don't exercise on a mark or sore over a pressure area. See a GP if a patch of skin doesn't change colour when you press it.
The general guidance for disabled adults does, and so does the advice on shoulders and skin. The specific amounts come from spinal cord injury trials, so read the guide for your own condition too.
WheelPower lists wheelchair sports and runs festivals and free online classes. Every Body Moves and Activity Alliance help you find inclusive activities near you.
Exercise education, not a diagnosis or treatment plan, and clinical review of these guides is pending. Stop and get advice for chest pain, unusual breathlessness, dizziness or fainting, or new pain, and check with your doctor or midwife first if they have told you to limit activity. Health disclaimer.
