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Elderly and aging manual wheelchair users have an increased risk for accelerated loss of function and mobility that greatly limits independence and affects quality of life. This review addresses important issues for preserving function and mobility among elderly and aging individuals who use a manual wheelchair by presenting the current available evidence and recommendations. These include recommendations for maximizing function by decreasing pain, improving the ability to self-propel, and prolonging mobility and endurance through ergonomics, individualized wheelchair selection and configuration, and adaptations for increasing the capacity to handle the daily mobility demands through training, strengthening, and exercise. Each recommendation is supported by current research in each relevant area.