Every discharge plan for a dependent patient quietly assumes a second body: the daughter, husband or grandson who will perform the transfers once the clinical team leaves. Rehabilitation clinicians spend weeks restoring a patient’s function. Far less time goes to the person whose spine, shoulders and knees will absorb the load of that patient’s care every day.

That gap matters. According to the AARP and National Alliance for Caregiving’s Caregiving in the U.S. 2025 report, 63 million Americans now provide unpaid care, roughly 1 in 4 adults. About 65% help with activities of daily living, and nearly 1 in 4 provide 40 or more hours of care per week. Yet only 11% report receiving any training for ADL and IADL tasks.

In musculoskeletal terms, that is a large, untrained workforce performing some of the highest-risk lifts in healthcare without equipment, coworkers or injury protocols.

What the evidence says about caregiver pain

The clearest data come from a study led by occupational therapist Amy Darragh at The Ohio State University, published in the Journal of Applied Gerontology. Over four weeks of tracking, 94% of informal caregivers reported musculoskeletal pain in at least one body region. Low back pain led at 76%, followed by knee, shoulder and wrist pain at 43% each.

The functional consequences were just as striking. 78% said pain interfered with their ability to provide care, and 66% said it reduced their quality of life. The tasks they rated most demanding were transfers, toileting, bathing, stair negotiation and recovering a loved one after a fall.

The sample was small, but the pattern is consistent with what clinicians see in practice. When a caregiver’s back fails, the care plan fails with it, and the patient is often readmitted or moved to a facility.

Why home transfers exceed safe limits

Occupational health research has already done the math. Applying the revised NIOSH lifting equation to patient handling, NIOSH ergonomist Thomas Waters concluded that about 35 pounds is the maximum recommended load for a person lifting a patient under typical conditions. As he noted, patients are not shaped like boxes, and almost every manual lift of an adult exceeds that limit.

Hospital staff work under that guidance with ceiling lifts, sit-to-stand devices and a second set of hands. The home caregiver usually has none of these. Their conditions are also worse:

• Low beds, soft mattresses and recliners that force deep trunk flexion
• Narrow bathrooms that require twisting during toilet and tub transfers
• No second person for a two-assist transfer
• Repetition across 24 hours, including night-time toileting when fatigue is highest
• Fall recovery from the floor, the single worst lift in the home

Many caregivers are also older adults themselves, with their own degenerative joint disease, osteopenia or prior back injury.

Five things rehab clinicians can do before discharge

1. Screen the caregiver, not just the home. Ask about current back, shoulder and knee pain, prior injuries and how many transfers a day they expect to perform. A caregiver with active low back pain needs a different plan than a healthy adult child.
2. Teach two or three transfers, not ten. Pick the transfers the patient will actually need, such as bed to chair, chair to toilet and car. Have the caregiver perform each one with you until the movement is consistent.
3. Coach body mechanics in the real environment. Bed height, a wide base of support, close positioning and pivoting with the feet instead of the trunk matter more in a cramped bathroom than in a therapy gym.
4. Prescribe equipment like a medication. Gait belts, transfer boards, raised toilet seats, grab bars, bed rails and, where appropriate, mechanical lifts should be specified, justified and trained. Equipment that is delivered but never demonstrated tends to sit in a closet.
5. Plan for the fall. Teach the caregiver when not to lift, how to make the patient comfortable on the floor and when to call for help. The CDC reports that over 14 million adults 65 and older, about 1 in 4, fall each year, so this conversation is not optional.

Caregiver training now has billing codes

Since January 1, 2024, Medicare has recognized caregiver training services under CPT codes 97550, 97551 and 97552. According to an APTA practice advisory, the codes cover training in transfers, mobility, ADLs, IADLs and safety, and the patient does not need to be present.

Services must sit within a plan of care, with documented patient consent and a clinical rationale. Commercial coverage varies, so verify with each payer. For many clinics, these codes turn caregiver education from an unpaid add-on into a documented, reimbursable part of treatment.

When the caregiver is also the paid aide

A growing share of family caregivers are no longer strictly unpaid. Medicaid home and community-based services in many states allow eligible adults to choose their own attendant, and that attendant is often a relative. Programs built on consumer-directed care in Missouri, for example, let participants direct their own personal care and, in many cases, have a family member or friend paid to provide it. Eligibility rules and which relatives can be paid vary by state and program.

For clinicians, this shift is an opening. A paid family caregiver has a formal role, regular hours and often a supporting agency, which makes it easier to schedule training sessions, follow up on technique and request equipment. It also means injury prevention protects both a family’s health and its income.

When you document a home program, ask whether the caregiver is enrolled in a state program or working through a home care agency. That agency may be able to reinforce your training, report changes in the patient’s mobility and flag when the caregiver starts to struggle.

Treat the caregiver as part of the case

Musculoskeletal medicine has spent decades building safe patient handling programs for nurses and aides. The same evidence applies to the family caregiver at home, who faces heavier loads, worse ergonomics and no backup.

A short caregiver screen, two or three well-taught transfers, the right equipment and a fall plan can keep both people in the home longer. With dedicated billing codes now in place, there is little reason to leave the second body out of the plan of care.

Author bio (placeholder): [Author name] writes about home-based care, caregiver health and rehabilitation. [Add one line of credentials.]

References

• AARP and National Alliance for Caregiving, Caregiving in the U.S. 2025 press release
• Darragh A. et al., Journal of Applied Gerontology, 2014, summarized in Rehab Management
• Relias Media, NIOSH sets 35-lb limit as the max for safe lifts
• CDC, Older Adult Falls Data
• APTA, Practice Advisory: Caregiver Training Codes

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