New Stroke Rehabilitation Guideline Emphasizes Early, Whole-Person Recovery
For the nearly 800,000 Americans who experience a stroke each year, recovery can involve much more than regaining strength or relearning how to walk. It can mean rebuilding independence, adapting to cognitive and communication changes, managing fatigue and mental health, and figuring out what life looks like after stroke.
A new national guideline led by University of Utah occupational therapy researcher Lorie Richards, Ph.D., calls for stroke rehabilitation to begin early and address the full range of challenges survivors and their families may face.
- Stroke rehabilitation should begin as soon as a person is medically stable, ideally within 48 hours.
- New guidance expands the focus on mental health, sleep, fatigue and other challenges after stroke.
- Rehabilitation should be individualized and continue to evolve as recovery progresses.
Richards, an associate professor in the Department of Occupational and Recreational Therapies and licensed occupational therapist, chaired the volunteer writing group for the 2026 Guideline for Adult Stroke Rehabilitation and Recovery from the American Stroke Association, a division of the American Heart Association. Published in Stroke, the guideline replaces recommendations issued in 2016 and incorporates a decade of new research on stroke rehabilitation and recovery.
Rehabilitation Should Start Early
One of the guideline's central messages is straightforward: people who have experienced a stroke should receive rehabilitation as soon as they are medically stable—ideally within 48 hours.
Research shows that beginning rehabilitation early can lead to better outcomes, although moderate- to high-intensity exercise and task practice should not begin within the first 24 hours after a stroke.
For Richards, one of the most important messages for patients and families is to advocate for high-quality rehabilitation.
“Get rehabilitation, get as much rehabilitation as you can. Push for getting really good rehabilitation, particularly inpatient rehabilitation, if you're a candidate for that. And make sure that caregivers get some training and get some emotional support while they're in rehabilitation.”
Where rehabilitation happens will vary depending on the severity of the stroke and an individual's needs. Some people may return home and receive outpatient care, while others may need inpatient rehabilitation, skilled nursing care or other services.
Regardless of the setting, rehabilitation should be individualized and supported by a coordinated team that may include occupational therapists, physical therapists, speech-language pathologists, rehabilitation nurses, neurologists, psychologists, social workers, recreational therapists and other health professionals.
Recovery Is More Than Physical
The updated guideline also places greater emphasis on aspects of stroke recovery that may be less visible, including mental health, sleep and post-stroke fatigue.
“New this year is all the expanded information about mental health, about the fact that sleep is important and sleep quality, [and] the recognition that many people experience some significant fatigue after stroke that's different than just being tired from working hard all day,” Richards said.
Depression and anxiety can be common after stroke, which is why the guideline recommends continued monitoring and screening for mental health concerns.
Richards says those challenges can be closely connected to the rehabilitation process itself. A stroke can suddenly change a person's abilities, independence, relationships and expectations for the future.
“There’s a lot of grief for what has been lost, and there’s a lot of being able to go through the process of understanding who the new me is,” Richards said.
Depression, anxiety and apathy can also make it more difficult for someone to engage fully in rehabilitation, potentially affecting both recovery and quality of life.
That broader view of recovery is reflected throughout the new guideline. Rehabilitation may address returning to work, parenting, sleep, pain, sexual function, relationships, recreation and participation in other activities that are important to an individual's life.
Supporting Caregivers, Too
Stroke recovery can also place significant demands on family members and caregivers.
About 2.7 million people in the United States provide care for stroke survivors, often helping with daily activities, household responsibilities and physical needs. Caregivers themselves may experience stress, depression or anxiety. The new guideline emphasizes including them in rehabilitation planning and providing education, training and emotional support throughout the recovery process.
Recovery Doesn't Have a Deadline
Perhaps most importantly, the guideline recognizes that stroke recovery does not follow a single timeline.
Progress may continue for months or years, and rehabilitation needs can change over time. The guideline recommends periodically reassessing a survivor's goals, progress and abilities rather than viewing rehabilitation as having a clearly defined endpoint.
“Stroke rehabilitation is complicated,” Richards said. “A stroke can affect many of the skills people rely on for daily living, and even the most routine activities involve multiple physical, cognitive and communication abilities working together.”
Because every stroke and every survivor are different, rehabilitation needs to reflect the life each person is working to rebuild.
“The goal is to help individuals gain as much independence as possible to perform everyday activities while improving their overall quality of life,” Richards said.
Key Takeaways
- Start rehabilitation early. Rehabilitation should begin once a person is medically stable, ideally within 48 hours after stroke.
- Treat the whole person. Recovery can involve physical abilities, cognition, communication, mental health, sleep, fatigue and participation in everyday life.
- Individualize rehabilitation. The right setting, therapies and goals depend on each person's stroke and needs.
- Support caregivers. Families and caregivers need training, education and emotional support as part of the rehabilitation process.
- Keep reassessing recovery. Improvement can continue for months or years, and rehabilitation goals should evolve with the survivor.