The 2026 AHA/ASA guideline reframes stroke rehabilitation as a longitudinal process without a defined endpoint. Rehabilitation begins during acute care but should continue through reassessment, community reintegration and re-engagement with therapy when new needs emerge.
When should mobilization begin after stroke?
For patients with acute stroke, graduated mobilization beginning 24–48 hours after onset is recommended to improve functional outcomes and quality of life (Class 1, LOE A).
| Timing | Recommendation |
|---|---|
| 24–48 hours | Graduated mobilization recommended |
| <24 hours | Avoid high-dose mobilization |
Importantly, high-dose mobilization within the first 24 hours should not be performed because it may worsen neurological and functional outcomes (Class 3: Harm, LOE A).
In practice: Early rehabilitation matters, but more intensive rehabilitation is not necessarily better during the hyperacute period.
Where should postacute rehabilitation occur?
Patients who require postacute rehabilitation should receive organized, coordinated, interprofessional care.
When a patient qualifies for an inpatient rehabilitation facility (IRF), the guideline recommends IRF rather than skilled nursing facility (SNF) care because it is associated with greater functional improvement and higher rates of community discharge.
For patients with mild to moderate activity limitations, early supported discharge with coordinated multidisciplinary rehabilitation is also recommended. Family-led home rehabilitation alone, however, has not demonstrated benefit over early discharge alone.
Does rehabilitation end at discharge?
No. This is perhaps the most important conceptual change.
Stroke recovery is nonlinear and extends beyond restoration of physical function. The guideline recommends periodic reassessment and re-engagement with rehabilitation to identify new goals, address functional decline and respond to changing needs.
In practice: Completing a rehabilitation programme should not automatically mean that a patient’s rehabilitation needs have ended.
How much exercise should stroke survivors perform?
Physical activity is part of long-term stroke management. Exercise should be individualized according to functional ability, comorbidities, goals and tolerance.
- 150–300 minutes/week of moderate-intensity aerobic activity, or 75–150 minutes/week of vigorous activity
- Aerobic training 3–5 days/week
- Strength training 2–3 days/week
- Balance training 2–3 days/week
How should depression and anxiety be managed?
Mental health should be incorporated into routine stroke rehabilitation.
Depression screening with a validated instrument is recommended between 3 days and 3 months after stroke. Screening for depression, anxiety and other psychiatric symptoms should then be repeated at 3 months, 6 months and throughout the lifespan.
Positive screens require appropriate clinical evaluation and, when indicated, treatment. Mood symptoms should not be dismissed as an inevitable consequence of stroke: they can directly interfere with rehabilitation participation and recovery.
What role does telerehabilitation have?
Telehealth should be considered particularly when patients cannot easily travel for rehabilitation. It can improve access, maintain continuity across transitions of care and enable rehabilitation to continue at home.
Available studies generally suggest outcomes comparable with conventional rehabilitation in selected patients with mild to moderate impairments, although the evidence remains heterogeneous.
What should clinicians avoid?
A particularly practical safety recommendation concerns the hemiplegic shoulder.
Overhead pulley exercises should not be used in patients with glenohumeral subluxation, shoulder weakness or shoulder pain after stroke (Class 3: Harm, LOE C-EO). Improper aggressive overhead range-of-motion exercise may cause more harm than benefit.
What is the ultimate goal of rehabilitation?
The goal extends beyond walking and basic activities of daily living.
The 2026 guideline places greater emphasis on participation and reintegration, including social activity, recreation, sexual function, return to work and driving. Patients with deficits that could impair driving should undergo appropriate structured assessment, including an on-road test when indicated.
Final clinical takeaway
The 2026 AHA/ASA guideline moves stroke rehabilitation away from the concept of a finite episode of therapy. Start rehabilitation appropriately, avoid excessive mobilization in the first 24 hours, prescribe ongoing exercise, screen mental health longitudinally and reassess rehabilitation needs over time.
The goal is not simply discharge or independence in activities of daily living—it is meaningful participation in life.
Full 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. Published online 27 August 2026. doi:10.1161/STR.0000000000000536.