New stroke rehabilitation guideline points to earlier, broader and more personalised care

The way you deliver stroke rehabilitation could be about to shift. A major new guideline calls for therapy that starts earlier, spans the whole recovery journey and is tailored to each person, and it asks physiotherapists to rethink some long-standing habits, from how the hemiplegic shoulder is treated to how much intensity is safe in the first day. Published by the American Heart Association and American Stroke Association as their first update in a decade, the 2026 Guideline for Adult Stroke Rehabilitation and Recovery is a practical prompt to revisit day-to-day practice.

Stroke remains one of the leading causes of long-term disability, and rehabilitation is central to how people rebuild function and independence afterwards. The American Heart Association and American Stroke Association have now published the 2026 Guideline for Adult Stroke Rehabilitation and Recovery in the journal Stroke, their first major update in this area in a decade. It reviews the evidence across nearly every stage of recovery, from the first hours in hospital through to living well in the community months or years later, making it a useful reference point for anyone working in neurological physiotherapy and a prompt to revisit some familiar habits.

One of the headline shifts is in framing. The guideline describes recovery as building “a resilient new self” rather than simply returning to a pre-stroke baseline, and it maps recovery across five stages from hyperacute, the first 24 hours, through to chronic, beyond 6 months. This encourages you to think about goals and interventions that stay relevant well beyond the early weeks.

On timing, the guideline supports beginning rehabilitation in the acute hospital phase, with graduated mobilisation ideally starting between 24 and 48 hours after the stroke. It draws a clear safety line here, advising against very early, higher intensity mobilisation within the first 24 hours because the evidence links it to worse outcomes, while supporting moderate to high intensity exercise and task practice once past that window. Early supported discharge, where people with mild-to-moderate impairments move home with a coordinated team, is now recommended as achieving outcomes comparable to hospital-based rehabilitation.

Several recommendations are worth flagging because they may change what you stop doing. For hemiplegic shoulder pain, the guideline recommends against overhead pulley exercises in people with subluxation, weakness or pain, classifying the practice as more likely to harm than help. Splints and taping are not recommended for preventing wrist and finger spasticity. And regular benzodiazepine use for post-stroke anxiety is now flagged as potentially harmful, given the risks to cognition, falls and mortality.

There is plenty to do more of, too. A formal falls prevention programme is now recommended for every person after stroke, given that 40% to 58% fall within the first year, supported by balance work, tai chi and dual-task training that combines movement with a cognitive task. Botulinum toxin injection is a strong recommendation for both upper and lower limb spasticity that interferes with function or gait. Screening for depression and anxiety is recommended at 3 and 6 months and across the lifespan, and swallowing should be screened within 24 hours of admission and before anything is taken by mouth.

It is worth remembering that this is a US guideline, so some of the service structures it describes are specific to the United States. The clinical principles, though, are broadly relevant wherever you practise, and it is a strong evidence synthesis to read alongside your own national guidance.

We will be reviewing the relevant Physiopedia pages and updating them to reflect these new recommendations, so keep an eye on our stroke rehabilitation resources over the coming weeks. You can read the full guideline, 2026 Guideline for Adult Stroke Rehabilitation and Recovery, in Stroke.

In short, the 2026 guideline points neurological physiotherapy towards earlier, broader and more personalised rehabilitation across the whole recovery journey. It reinforces several practice-changing messages, from stopping overhead pulley exercises for hemiplegic shoulder pain to prioritising falls prevention, spasticity management and timely mental health and swallowing screening, with physiotherapists central to the multidisciplinary team.