2026 AHA/ASA Stroke Rehabilitation & Recovery Guideline Summary

This is a condensed summary of the 2026 Guideline for Adult Stroke Rehabilitation and Recovery (Richards et al.), replacing the 2016 guideline (Winstein et al.). It applies to adults after ischemic or hemorrhagic stroke and is endorsed by AAPM&R, ACRM, ASNR, APTA, and ATRA, with AAN affirmation of value. Recommendations are listed by Class of Recommendation (COR) and Level of Evidence (LOE) where clinically impactful.

1. The Rehabilitation Program

Levels of Care

• Organized, coordinated, interprofessional postacute rehabilitation is recommended (COR 1, LOE A)
• Patients who qualify for inpatient rehabilitation facility (IRF) care should be treated in an IRF in preference to a skilled nursing facility (SNF) (COR 1, LOE B-NR)
• Organized, coordinated community-based interprofessional care for outpatient/home-based rehab (COR 1, LOE C-LD)
• SNF care can be useful when patients cannot return home and do not qualify for (or lack access to) IRF care, or after IRF when ongoing needs prevent discharge home (COR 2a)

Early Supported Discharge (ESD)

• ESD with multidisciplinary services is recommended for mild to moderate activity limitations — outcomes comparable to hospital-based rehabilitation (COR 1, LOE B-R)
• Early discharge with family-led home rehabilitation adds nothing over early discharge alone (COR 3: No Benefit, LOE B-R)

Acute-Phase Mobilization

• Begin graduated mobilization 24–48 hours after stroke onset to improve functional outcomes and quality of life (COR 1, LOE A)
• High-dose mobilization within the first 24 hours should NOT be performed — risk of neurological worsening and worse functional outcomes (COR 3: Harm, LOE A)

2. Prevention & Medical Management of Comorbidities

Skin Breakdown & Contractures

• Regular skin assessments with valid instruments (e.g., Braden Scale) during acute and postacute care (COR 1, LOE A)
• Minimize friction (foam dressings, pressure-reducing surfaces), reduce moisture, maintain nutrition/hydration (COR 1, LOE A)
• Educate patients, caregivers, and clinical staff about skin-breakdown prevention in limited mobility (COR 1, LOE B-R)
• Stretching programs are reasonable in spastic limbs to prevent contracture (COR 2a, LOE B-NR)
• May be considered (COR 2b): positioning the hemiplegic shoulder in external rotation with pain-free abduction and elbow extension, 30 min twice daily while sitting or in bed; resting ankle splints in bed; serial casting or static adjustable splints for mild-moderate elbow/wrist contractures; surgical release (brachialis, brachioradialis, biceps) for substantial painful elbow contractures

VTE Prevention

• Intermittent pneumatic compression (IPC) in acute stroke with moderate-severe mobility limitation (COR 1, LOE B-R)
• Elastic compression stockings are NOT effective (COR 3: Harm, LOE B-R)
• Benefit of prophylactic-dose heparin (UFH or LMWH) is unclear in both ischemic stroke and ICH given hemorrhage risk (COR 2b); benefit of LMWH over UFH is uncertain (COR 2b, LOE B-R)

Bladder & Bowel Dysfunction

• Assess premorbid urological issues and urinary retention (bladder scan or postvoid catheterization) to build a bladder care plan (COR 1, LOE B-NR)
• Remove indwelling urinary catheters within 24 hours after placement in postacute rehabilitation (COR 1, LOE B-NR)
• Might be reasonable (COR 2b): timed/prompted voiding, pelvic floor muscle training (chronic stroke), noninvasive electrical stimulation, premorbid bowel function assessment

Hemiplegic Shoulder Pain (HSP)

• Assess shoulder (subluxation, spasticity, ROM, sensory changes) and screen for spatial neglect to guide prevention (COR 1, LOE B-NR)
• Patient/caregiver education on shoulder care before discharge or transitions (COR 1, LOE B-NR)
• Positioning devices and slings are reasonable for subluxation (COR 2a, LOE B-R)
• Botulinum toxin injection can be useful for spastic shoulder muscles with pain (COR 2a, LOE B-R)
• Peripheral nerve stimulation is reasonable for neuropathic HSP (allodynia, hyperpathia) (COR 2a, LOE B-R)
• Useful adjuncts (COR 2a): corticosteroid injection, suprascapular nerve block, high-intensity laser, shock-wave therapy, NMES, Kinesio taping, acupuncture
• Overhead pulley exercises are NOT recommended (COR 3: Harm, LOE C-EO)

Central Poststroke Pain (CPSP)

• Diagnose using proposed standardized diagnostic criteria (COR 1, LOE C-EO); individualize pharmacotherapy (COR 1, LOE C-EO)
• First-line: duloxetine, lamotrigine, or amitriptyline (COR 2a, LOE B-R)
• Second-line: pregabalin or gabapentin (COR 2b, LOE B-NR)
• Multidisciplinary pain management alongside pharmacotherapy is reasonable (COR 2a)

Falls

• Formal fall prevention program (COR 1, LOE B-NR); home/environmental modification education (COR 1, LOE C-EO)
• Reasonable (COR 2a): balance exercises, annual fall-risk evaluation, tai chi, dual-task (motor + cognitive) training
• Exergaming may be reasonable (COR 2b, LOE B-R)

Mental Health: Depression & Anxiety

• Early screening for poststroke depression (3 days–3 months) with a valid instrument (COR 1, LOE A); periodic rescreening for depression, anxiety, and other psychiatric symptoms at 3 and 6 months and throughout the lifespan (COR 1, LOE B-NR)
• Use adapted instruments/supported communication for patients with communication impairment (COR 1, LOE C-LD)
• Positive screens get comprehensive evaluation by a professional with depression expertise (COR 1, LOE C-EO)
• Pseudobulbar affect: dextromethorphan/quinidine is recommended in chronic stroke when episodes cause distress (COR 1, LOE A)
• Antidepressants can be beneficial for established poststroke depression (COR 2a, LOE A); SSRIs for poststroke anxiety (COR 2a, LOE B-R); CBT for either (COR 2a, LOE B-R)
• Exercise ≥3×/week can reduce depressive symptoms (COR 2a, LOE A)
• May be considered (COR 2b): rTMS, combined pharmacological + nonpharmacological treatment, ACT, music therapy, acupuncture, mindfulness
• Prophylactic antidepressants are NOT recommended for routine PSD prevention (COR 3: No Benefit, LOE A)
• Regular benzodiazepine use for poststroke anxiety is potentially harmful — impaired cognition, falls, mortality (COR 3: Harm, LOE B-NR)

Osteoporosis

• FRAC-Stroke score can be useful to predict fracture risk after ischemic stroke (COR 2a, LOE B-NR)
• Physical activity (aerobic, resistance, balance) can improve bone mineral density and reduce fracture risk (COR 2a, LOE B-NR)

Sleep & Poststroke Fatigue (New Section)

• CBT can improve fatigue and sleep quality (COR 2a, LOE B-R); light therapy may be considered for fatigue (COR 2b, LOE C-LD)
• Fluoxetine is NOT recommended for poststroke fatigue (COR 3: No Benefit, LOE B-R)

3. Assessment

• Formal assessment across the ICF framework — body structure/function, activity, participation, personal and environmental factors — to inform treatment and discharge planning (COR 1, LOE B-NR)
• Valid standardized instruments from the acute phase through all stages of recovery (COR 1, LOE B-NR); repeated follow-up for at least the first year is reasonable (COR 2a, LOE B-NR)
• Motor: dynamometry for strength quantification (COR 1); standardized upper/lower extremity motor-impairment and upper-extremity-function instruments (COR 1); mobility assessment in patients with walking capacity (COR 1); wearable sensors for real-world activity (COR 2a)
• Communication: SLP-led screening/assessment covering speech, hearing, verbal and nonverbal language, pragmatics, and cognition (COR 1, LOE B-NR); use formal and informal valid instruments — patient-reported, performance-based, clinician-reported, and interviews — at baseline and reassessment (COR 1, LOE B-NR); account for cultural background, prestroke language use, and dominant language and use patterns (COR 1)
• Cognition/perception: brief multidomain performance-based screens with good diagnostic accuracy (COR 1, LOE B-NR), then comprehensive validated evaluation including real-world activities when impairment is suspected (COR 1)
• Sensory: comprehensive evaluation of somatosensation, vision, and hearing (COR 1, LOE B-NR); performance-based visual screening instead of self-report alone (COR 1, LOE B-NR)

4. Sensorimotor Impairments & Activities

Physical Activity & Lifestyle

• Individually tailored exercise program for cardiorespiratory fitness, mobility, and vascular risk reduction (COR 1, LOE A); continue from rehabilitation into home/community for cognitive health (COR 1, LOE A)
• Clinicians should collaborate with the patient — respecting exercise guidelines and personal preferences — to set an achievable physical activity program (COR 1, LOE C-EO)
• Reduce dietary sodium by ≥1 g/day as part of healthy eating (COR 1, LOE B-R); a Mediterranean diet is reasonable (COR 2a, LOE B-R)
• Smoking: cessation counseling with or without drug therapy (COR 1, LOE A); avoid secondhand smoke (COR 1, LOE B-NR)
• Alcohol above 2 drinks/day (men) or 1 drink/day (women): counseling and behavioral strategies to reduce or abstain (COR 1, LOE B-NR); stimulant abuse or IV-drug-use endocarditis: counsel to stop and refer to addiction programs (COR 1, LOE C-EO); substance use disorder: specialized addiction treatment (COR 1, LOE B-NR)

Spasticity

• Targeted botulinum toxin injection for upper extremity spasticity (ROM, positioning, dressing, hygiene) and lower extremity spasticity interfering with gait (both COR 1, LOE A)
• Use instrumented guidance (ultrasound, e-stim, or EMG) for injections (COR 1, LOE B-R)
• Intrathecal baclofen is reasonable for severe refractory spasticity (COR 2a, LOE B-R)
• Oral antispasticity agents may be useful for generalized spasticity but sedation/weakness are dose-limiting (COR 2b, LOE A); NMES/vibration give temporary adjunctive benefit (COR 2b, LOE A)
• Splints and taping are NOT recommended for preventing wrist/finger spasticity (COR 3: No Benefit, LOE B-NR)

Balance & Ataxia

• Evaluate balance, balance confidence, and fall risk to set the treatment plan (COR 1, LOE C-EO)
• Prescribe and fit an assistive device or orthosis, if appropriate, to improve balance and cut fall risk (COR 1, LOE A)
• Reasonable (COR 2a): postural training and task-oriented therapy for ataxia, tai chi, VR/gaming-based balance training, core stabilization exercises

Gait & Mobility

• Evidence-based, goal-oriented multidisciplinary physical rehabilitation (COR 1, LOE A)
• Task-specific training focused on overground walking, stepping, and balance (COR 1, LOE A)
• In subacute or chronic stroke, moderate- to high-intensity stepping / high-intensity interval walking work is effective (COR 2a, LOE B-R); high-dose therapy (1–2 h sessions, 5×/week, 4–8 weeks, moderate-vigorous intensity) improves speed and endurance (COR 2a)
• Resistance training of both legs — not the less-affected leg alone (COR 2a, LOE A)
• Also effective (COR 2a): rhythmic auditory cueing, lower-limb CIMT, motor imagery/mirror therapy with bilateral movements, interactive exergame/VR gait training
• May be considered (COR 2b): FES of the affected leg + exercise, water-based exercise (chronic stroke), acupuncture with rehab, TENS, visual biofeedback, medical treatment of spasticity to improve walking speed
• NOT recommended over task-specific overground training in ambulatory patients: robot-assisted gait training (COR 3: No Benefit, LOE A) and light-moderate treadmill training with or without body-weight support (COR 3: No Benefit, LOE A)
• Neurodevelopmental (Bobath) approaches are NOT recommended (COR 3: No Benefit, LOE B-R)

Upper Extremity & ADLs

• ADL training (COR 1, LOE B-R) and IADL training (COR 1, LOE B-NR) tailored to needs and discharge setting
• Repetitive, progressively graded functional task practice — including CIMT and modified CIMT (COR 1, LOE A)
• Robotic-assisted rehab is reasonable in moderate-severe hemiparesis as added dose (COR 2a, LOE A)
• NMES is reasonable for early shoulder subluxation/minimal volitional movement (COR 2a, LOE A); may be considered for chronic distal moderate-severe impairment (COR 2b)
• Reasonable adjuncts (COR 2a): mental practice, strength training, VR, active somatosensory discrimination training (>6 weeks poststroke), mirror therapy, bilateral training
• Vagus nerve stimulation paired with high-dose task-specific training may be considered (COR 2b, LOE B-R)
• Bobath/NDT is NOT recommended for the upper limb (COR 3: No Benefit, LOE B-R)

Adaptive Equipment & Orthotics

• AFO or FES for poststroke hemiplegia improves balance and mobility (COR 1, LOE A)
• Adaptive/assistive devices for activity limitations (COR 1, LOE B-NR); canes/walkers for gait or balance impairment (COR 1, LOE B-NR); wheelchairs for nonambulatory patients (COR 1, LOE C-LD)

Visual Impairments

• Eye exercises improve convergence insufficiency (COR 1, LOE A)
• Visual field cuts: prisms and compensatory scanning training can be useful (COR 2a, LOE B-R) — scanning improves vision-related quality of life but not the field deficit itself
• Audio-visual spatial exploration training (vs visual-only) for visual-spatial/perceptual deficits (COR 1, LOE B-R)
• Eye exercises, lenses, and colored filters are NOT recommended for visual-spatial/perceptual deficits (COR 3: No Benefit, LOE B-NR)

Dysphagia & Nutrition

• Screen within 24 hours of admission and before any oral intake using a formal validated tool that at minimum observes swallowing of liquids of different volumes (COR 1, LOE B-R/B-NR); rescreen within 24 h of arrival at each new care setting (COR 2a)
• For suspected dysphagia, instrumented swallow studies over bedside studies to verify aspiration, define mechanism, and set the least restrictive diet (COR 1, LOE B-NR); in acute stroke, reasonable within 4 days of admission or 24 h of extubation (COR 2a)
• Behavioral swallowing treatment is effective (COR 1, LOE B-NR); biofeedback is a useful addition (COR 2a, LOE B-R); pharyngeal electrical stimulation may be considered (COR 2b, LOE B-R)
• Early nutrition support in the acute phase (COR 1, LOE B-R); nutritional support remains effective in the subacute and chronic phases (COR 1, LOE B-NR)
• Gastrostomy (PEG) preferred over nasogastric tubes for chronic inability to swallow safely (COR 1, LOE B-NR); nasojejunal or intermittent oroesophageal feeding are reasonable short-term options (COR 2a)
• Sialorrhea: atropine or botulinum toxin may reduce drooling (COR 2b, LOE B-NR)

5. Cognition & Communication

Cognitive Rehabilitation

• Supervised, tailored, adaptive moderate- to high-intensity technology-supported cognitive training improves global cognition, attention, and working memory (COR 1, LOE B-R)
• Combining cognitive training with physical activity is reasonable (COR 2a, LOE B-R); embedding cognition in contextually relevant daily activities is reasonable (COR 2a, LOE C-LD)

Aphasia & Communication Disorders

• A variety of speech-language treatment approaches should be administered (COR 1, LOE A)
• Supported communication training for partners/facilitators (COR 1, LOE B-NR)
• Intensive aphasia treatment can be useful (COR 2a, LOE B-R); telerehabilitation is reasonable when face-to-face care is impractical (COR 2a, LOE A)
• Computerized treatment, implemented by an SLP, may supplement traditional aphasia therapy (COR 2b, LOE B-R); group/community-based treatment may facilitate restorative, compensatory, and interpersonal communication (COR 2b, LOE B-NR)
• Hearing loss: refer to audiology (COR 1, LOE B-NR); hearing aids + communication strategies (COR 2a)

Motor Speech Disorders (Dysarthria & Apraxia of Speech)

• Behavioral speech interventions (COR 1, LOE B-NR); respiratory training as adjuvant (COR 1, LOE B-R); AAC devices to supplement speech (COR 1, LOE C-LD)
• Nonspeech oral-motor exercises are NOT effective (COR 3: No Benefit, LOE B-R)

Spatial Neglect

• Visual eye-movement training (optokinetic stimulation, saccadic/smooth-pursuit training) is reasonable (COR 2a, LOE A); mirror therapy with conventional therapy is reasonable (COR 2a, LOE B-R)
• Prism adaptation (>10° shift) with conventional therapy may be reasonable (COR 2b, LOE B-R); limb activation or VR might be reasonable (COR 2b)
• Galvanic vestibular stimulation is NOT useful (COR 3: No Benefit, LOE B-R)

6. Transitions of Care & Community Reintegration

Continuity, Caregivers & Community Resources

• Individualized discharge planning for the hospital-to-home transition (COR 2a, LOE B-R); telehealth-delivered transitional care might be considered (COR 2b)
• Engage caregivers early and throughout rehabilitation — education with teach-back, and longitudinal tailored psychosocial/psychoeducational support for the caregivers themselves (all COR 2a, LOE B-R)
• Provide tailored information and referrals to community resources across the continuum (COR 1, LOE C-LD); the Post-Stroke Checklist can identify problems needing referral (COR 2a, LOE B-NR)
• Ongoing community- or home-based rehabilitation after hospital discharge (COR 1, LOE A); home-based multidisciplinary rehab is a reasonable alternative to clinic-based therapy (COR 2a, LOE B-R); after mild-moderate stroke, telerehabilitation is a reasonable alternative when in-person access is limited or absent (COR 2a, LOE B-R)

Participation & Reintegration

• In subacute and chronic stroke, individualized assessment/treatment plan for leisure and social participation (COR 1, LOE B-NR)
• Screen and discuss social health — isolation, loneliness, and limited social supports/networks — in all patients (COR 1, LOE B-NR)
• Facilitate personally meaningful leisure-time physical activity (COR 1, LOE B-NR); nature-based activity/green space exposure can be beneficial (COR 2a, LOE B-R); tai chi, qigong, yoga, adapted sports, music, dance, exergames may be incorporated (COR 2b)
• Sexual function: reasonable for providers to raise and discuss (COR 2b, LOE B-NR)
• Return to work: early tailored vocational rehabilitation via OT/vocational services, job-demand-matched assessment, modified duties, fatigue management, and early employer engagement are all reasonable (COR 2a, LOE B-R)
• Return to driving: refer patients with potentially driving-relevant impairments for an on-road test by an authorized examiner (COR 1, LOE C-LD); comprehensive clinician assessment of vision, perception, motor, and cognition (COR 2a); driving rehabilitation with an authorized person is reasonable after a failed on-road test or when impairments could affect safe driving (COR 2a, LOE C-LD); simulators may help estimate risk (COR 2b)

Reference

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