Stroke rehab guideline update: AHA/ASA says recovery starts early and never truly ends

Clinical takeaway: Stroke rehabilitation should begin as soon as patients are medically stable, ideally during the acute hospitalization, and continue as a longitudinal process tailored to evolving physical, cognitive, communication, and mental health needs. Clinicians should routinely reassess function, screen for depression and anxiety, and leverage home-based and telehealth options to extend access to care.

The American Heart Association (AHA) and American Stroke Association (ASA) have released their first comprehensive update to stroke rehabilitation guidance since 2016, reframing stroke recovery as an ongoing process rather than a time-limited intervention. The guideline highlights the importance of multidisciplinary, patient-centered rehabilitation that begins early and extends into community and home settings.

A central message is that comprehensive rehabilitation should address not only motor deficits but also cognition, communication, mood, pain, sleep, social participation, and caregiver needs. The writing committee emphasizes that recovery trajectories vary widely and that patients should undergo periodic reassessment and re-engagement in therapy throughout the recovery continuum.

The guideline recommends initiating rehabilitation during the acute phase of stroke care once patients are medically stable. Early supported discharge programs, when available, are endorsed for selected patients with mild to moderate impairments, allowing transition home with coordinated multidisciplinary rehabilitation services.

Several recommendations address long-term complications that can impair recovery. Routine and longitudinal screening for both poststroke depression and anxiety is recommended, with treatment and referral as appropriate. The guideline also recommends dextromethorphan/quinidine for patients with distressing chronic pseudobulbar affect, a common but often underrecognized poststroke condition characterized by involuntary episodes of laughing or crying. The guideline expands fall-prevention recommendations as well, including structured fall-prevention programs, balance training, dual-task training, and tai chi.

Technology plays a larger role in the updated document. Telerehabilitation is endorsed as a reasonable alternative when access to in-person rehabilitation is limited, particularly for community-based care, speech-language therapy, cognitive rehabilitation, and selected behavioral interventions.

The update also includes expanded guidance on poststroke pain syndromes. For central poststroke pain, recommended pharmacologic options include duloxetine, lamotrigine, and amitriptyline, with pregabalin and gabapentin as additional options. For hemiplegic shoulder pain, the guideline highlights interventions such as botulinum toxin injections, peripheral nerve stimulation, and other multimodal therapies, while specifically cautioning against overhead pulley exercises because of potential harm.

The guideline further reinforces regular physical activity after stroke, caregiver education and training, standardized outcome measurement, and the use of home- and community-based rehabilitation programs to support long-term recovery and participation in daily life.

What's changed since the 2016 guideline

• Reframes stroke rehabilitation as a lifelong, longitudinal process with ongoing reassessment rather than a discrete episode of care.
• Greater emphasis on early rehabilitation, coordinated care transitions, and early supported discharge programs.
• Expanded recommendations for routine screening and management of poststroke depression and anxiety.
• Expanded mental health recommendations beyond depression to include anxiety and emotional-behavioral sequelae; dextromethorphan/quinidine is recommended for patients with distressing chronic pseudobulbar affect.
• Increased support for telerehabilitation and technology-enabled rehabilitation services.
• New and expanded guidance on central poststroke pain and hemiplegic shoulder pain, including specific pharmacologic and interventional options.
• Stronger focus on fall-risk assessment and prevention, including structured programs, dual-task training, and tai chi.
• Expanded recommendations for home-based and community-based rehabilitation after discharge.
• Greater emphasis on caregiver education, social participation, quality of life, and patient-reported outcomes.

“Recovery after stroke is rarely linear, goes beyond physical function, and does not have a clearly defined endpoint,” the guideline authors wrote, emphasizing that rehabilitation should be viewed as a longitudinal process that evolves across the lifespan.

Source: Richards LG, et al. (2026 Aug 27) Stroke. 2026 Guideline for Adult Stroke Rehabilitation and Recovery: A Guideline From the American Heart Association and American Stroke Association