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.
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.
They recommend 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.
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 as achieving outcomes comparable to hospital-based rehabilitation.
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, given that roughly 40% to 58% of survivors fall within the first year.
Additional recommendations include balance exercises to reduce fall risk, annual fall-risk evaluation using a validated instrument, and home and environmental modification education for patients and caregivers. The American Heart Association and American Stroke Association emphasize the importance of these measures.
Mental health recommendations were substantially expanded, reflecting that poststroke depression affects roughly one-third of survivors and poststroke anxiety about one-quarter, both well above general-population rates.
One notable update 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.
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For spasticity, the guideline recommends botulinum toxin injection into localized upper-limb muscles to reduce spasticity and improve range of motion, dressing, and hygiene. This approach is expected to improve patient outcomes.
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. Instrumented swallow studies are now preferred over bedside evaluations when dysphagia is suspected.
For acquired communication disorders, which affect at least 30% of stroke survivors, the guideline supports computerized aphasia treatment as a supplement to traditional therapy and group-based treatment to support restorative and interpersonal communication goals.
The emphasis on early supported discharge may require caregivers to take on more responsibilities.
The guideline substantially expanded its caregiver-focused recommendations, reflecting that roughly 2.7 million Americans serve as stroke caregivers. Active, early, and ongoing caregiver engagement throughout rehabilitation can improve caregiver knowledge, mental health, and burden.
On return to work, the guideline recommends early, tailored vocational rehabilitation delivered by occupational therapy and vocational services, supported by assessment of vision, perception, dexterity, cognition, and job-specific demands, along with modified job duties and work adaptations where needed. This approach is critical for successful reintegration into the workforce.
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. This evaluation is essential for ensuring patient safety.