AHA/ASA Issue New Guideline for Adult Stroke Rehabilitation and Recovery

The American Heart Association (AHA) and American Stroke Association (ASA) have published the "2026 Guideline for Adult Stroke Rehabilitation and Recovery" in the journal Stroke, replacing the organizations' 2016 guideline on the same topic. The new document reflects a literature search conducted through late 2025 and introduces updated or new recommendations across nearly every stage of stroke recovery, from acute hospitalization through long-term community reintegration.¹

The guideline writing group, chaired by Lorie G. Richards, PhD, OTR/L, framed recovery as an open-ended process rather than a fixed endpoint, writing that it involves "the development of a resilient new self," rather than a simple return to a pre-stroke baseline.¹ The document organizes stroke recovery into 5 stages: hyperacute (0-24 hours), acute (1-7 days), early subacute (7 days to 3 months), late subacute (3-6 months), and chronic (beyond 6 months), and generally avoids specifying intervention timing across these stages unless safety data support doing so.

Levels of care and program organization

For patients who qualify, the guideline recommends treatment in an inpatient rehabilitation facility (IRF) over a skilled nursing facility (SNF) when both are options, citing observational data showing greater functional improvement and higher rates of community discharge with IRF care (Class 1, Level of Evidence B-NR). SNF care remains reasonable for patients who don't qualify for or lack access to an IRF, or who need additional recovery time after IRF discharge (Class 2a).¹

Early supported discharge (ESD), in which patients with mild to moderate impairments transition home with coordinated multidisciplinary services rather than continued inpatient care, is now recommended (Class 1, Level B-R) as achieving outcomes comparable to hospital-based rehabilitation. Notably, the guideline found no added benefit to family-led home-based rehabilitation on top of early discharge alone (Class 3: No Benefit).

Medical comorbidity management

This section of the guideline covers falls, mental health, pain syndromes, bone health, and sleep, several of which received substantially expanded recommendations.

Falls prevention is addressed with a formal program now recommended for all patients with stroke (Class 1), given that roughly 40% to 58% of survivors fall within the first year.¹

Additional recommendations include:

• Balance exercises to reduce fall risk (Class 2a, Level B-R)
• Annual fall-risk evaluation using a validated instrument appropriate to the care setting (Class 2a, Level B-NR)
• Home and environmental modification education for patients and caregivers (Class 1, Level C-EO)
• Tai chi training (Class 2a, Level B-R)
• Dual-task training combining motor and cognitive tasks (Class 2a, Level B-R)
• Exergaming, which may be reasonable but carries a lower-strength recommendation (Class 2b, Level B-R)

Mental health recommendations were substantially expanded, reflecting that poststroke depression (PSD) affects roughly one-third of survivors and poststroke anxiety about one-quarter, both well above general-population rates. Periodic screening for depression, anxiety, and other psychiatric symptoms is now recommended at 3 and 6 months and throughout the patient's lifespan (Class 1, Level B-NR), including in patients with impaired communication using adapted tools or supported communication strategies (Class 1, Level B-NR).

Antidepressants can be beneficial for treating established PSD (Class 2a, Level A), but prophylactic use to prevent depression before it develops is not recommended (Class 3: No Benefit, Level A). The guideline also flags a notable safety concern: regular benzodiazepine use for poststroke anxiety is now classified as potentially harmful, given increased risks of impaired cognition, falls, and mortality (Class 3: Harm, Level B-NR).

Central poststroke pain (CPSP), affecting roughly 7% to 11% of stroke survivors, now has standardized diagnostic criteria endorsed in the guideline for the first time, based on history, physical exam, and lesion imaging (Class 1, Level C-EO). Duloxetine, lamotrigine, and amitriptyline were identified as reasonable first-line pharmacologic options (Class 2a, Level B-R), with pregabalin or gabapentin as second-line choices (Class 2b, Level B-NR).

Sleep and poststroke fatigue is an entirely new section in this edition. Cognitive behavioral therapy can be beneficial for both fatigue and sleep quality (Class 2a, Level B-R); light therapy may be considered for fatigue specifically (Class 2b, Level C-LD); and fluoxetine is explicitly not recommended for treating poststroke fatigue (Class 3: No Benefit, Level B-R), based on null results from the FOCUS and EFFECTS trials.¹

Sensorimotor rehabilitation

One of the more notable practice-changing updates involves hemiplegic shoulder pain: the guideline now explicitly recommends against the use of overhead pulley exercises to increase range of motion or reduce shoulder pain in patients with glenohumeral subluxation, weakness, or pain, classifying the practice as causing more harm than benefit (Class 3: Harm, Level C-EO). Botulinum toxin injection remains a reasonable option for patients with spastic shoulder muscles (Class 2a, Level B-R).

For spasticity more broadly, the guideline recommends:

• Botulinum toxin injection into localized upper-limb muscles to reduce spasticity and improve range of motion, dressing, and hygiene (Class 1, Level A)
• Botulinum toxin injection into lower-limb muscles to reduce spasticity that interferes with gait (Class 1, Level A)
• Instrumented guidance (ultrasound, electrical stimulation, or EMG) for targeting injections, to improve efficacy (Class 1, Level B-R)
• Intrathecal baclofen for severe spasticity unresponsive to other interventions (Class 2a, Level B-R), citing the SISTERS trial showing superiority over oral medications
• Splints and taping are explicitly not recommended for preventing wrist and finger spasticity (Class 3: No Benefit, Level B-NR)

Cognitive, communication, and swallowing rehabilitation

For dysphagia, the guideline recommends screening as soon as possible and within 24 hours of admission, before any oral intake, using a formal validated tool (Class 1, Level B-R and B-NR). Instrumented swallow studies are now preferred over bedside evaluations when dysphagia is suspected, to verify aspiration risk and guide treatment with greater precision (Class 1, Level B-NR). Behavioral swallowing treatment remains a Class 1 recommendation for improving swallowing function and reducing negative health outcomes.¹

For acquired communication disorders, which affect at least 30% of stroke survivors, the guideline supports computerized aphasia treatment as a supplement to traditional therapy (Class 2b, Level B-R) and group-based treatment to support restorative and interpersonal communication goals (Class 2b, Level B-NR); it also recommends audiology referral for stroke survivors with hearing loss (Class 1, Level B-NR).

For spatial neglect, visual eye movement training approaches, such as optokinetic stimulation or saccadic and smooth pursuit training, are reasonable to improve visual-spatial impairment (Class 2a, Level A), and mirror therapy combined with conventional therapy is reasonable to improve functional independence (Class 2a, Level B-R).¹

Transitions, caregivers, and community reintegration

The guideline substantially expanded its caregiver-focused recommendations, reflecting that roughly 2.7 million Americans serve as stroke caregivers.¹ Active, early, and ongoing caregiver engagement throughout rehabilitation can improve caregiver knowledge, mental health, and burden (Class 2a, Level B-R), and longitudinal, tailored psychosocial or psychoeducational interventions after acute discharge can benefit caregiver mental health and family functioning (Class 2a, Level B-R).¹

On return to work, the guideline recommends early, tailored vocational rehabilitation delivered by occupational therapy and vocational services (Class 2a, Level B-R), supported by assessment of vision, perception, dexterity, cognition, and job-specific demands, along with modified job duties and work adaptations where needed. The guideline notes that median income drops by nearly 30% after stroke on average, with larger relative losses among lower-income survivors, underscoring the stakes of successful vocational reintegration.

For return to driving, the guideline recommends referral for a formal on-road test administered by an authorized evaluator for patients with cognitive, perceptual, or physical impairments that could affect safe driving (Class 1, Level C-LD), while acknowledging that no current neuropsychological test or screening battery reliably predicts which patients need this formal evaluation.¹

REFERENCES
1. Richards LG, Ifejika NL, Stein J, et al. 2026 Guideline for Adult Stroke Rehabilitation and Recovery: A Guideline From the American Heart Association and American Stroke Association. Stroke. 2026;57:e00-e00. doi:10.1161/STR.0000000000000536