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Living guidelines updates

The Stroke Foundation’s Clinical Guidelines for Stroke Management have evolved into the world's first living stroke guidelines as the next generation of health evidence translation.

On this page:

Draft recommendations for public consultation

When new research evidence leads to a change in recommendations, our Guidelines Working Group prepares drafts to be submitted to the NHMRC for approval under section 14A of the National Health and Medical Research Council Act 1992.

There are currently no draft recommendations for public consultation.


New and updated recommendations

Recommendations for the following topics have been updated based on new research evidence, in accordance with the 2016 NHMRC Standards for Guidelines.

Topic Date Change
Pre-hospital care (Chapter 1) 5/08/2022 New recommendation for pre-hospital treatment in a mobile stroke unit, for eligible patients in major cities.
Assessment for rehabilitation (Chapter 3) 5/08/2022 Updated wording in practice point to clarify that options include locally developed assessment tools (not subject to public consultation).
Aphasia (Chapter 5) 5/08/2022 Speech and language therapy now recommended to improve reading and auditory comprehension, and general expressive and written language, in addition to functional communication. Upgraded from weak to strong recommendation for early aphasia therapy starting in the first 4 weeks post stroke. New weak recommendation for intensive aphasia therapy for stroke survivors with chronic aphasia, plus changes to weak recommendation for intensity of aphasia therapy in the acute phase. Updated wording in weak recommendation against brain stimulation.
Dysarthria (Chapter 5) 5/08/2022 Tailored interventions that include speech production tasks targeting connected speech may be provided, e.g. reducing rate of speaking, emphasising articulatory placement or increasing loudness. Removed recommendation against non-speech oromotor exercises, which is addressed in the practical info of the main recommendation.
Prevention of depression (Chapter 6) 5/08/2022 Changed from weak recommendation against to weak recommendation for antidepressant medication.
Treatment for depression (Chapter 6) 5/08/2022 Recommendation for antidepressants changed from strong to weak, plus new recommendation that psychological therapy may be used, and updated recommendation for structured exercise programs to include resistance training. Non-invasive brain stimulation changed to weak recommendation for, from weak against.
Treatment for anxiety (Chapter 6) 5/08/2022 New consensus recommendation that psychological therapy and/or relaxation strategies may be trialled, with the addition of pharmacotherapy carefully considered.
Personality and behaviour (Chapter 6) 5/08/2022 New consensus recommendation that behavioural changes should be assessed and addressed through individually tailored interventions for survivors of stroke and their families/carers.
Pressure injury (Chapter 6) 5/08/2022 Reestablished practice point that staff and carers of patients at risk of pressure injuries should be trained to assess, provide care and treat pressure injuries consistent with existing guidelines.
Pre-hospital care (Chapter 1) 22/12/2021 New practice point for regular education to help clinicians identify stroke patients.
Acute stroke telehealth services (Chapter 3) 22/12/2021 New topic with recommendation for telestroke systems to help assess patients for thrombolysis and transfer for endovascular therapy, where 24/7 onsite specialists are unavailable.
Head position (Chapter 3) 22/12/2021 New topic with recommendation that any position may be used in the first 24 hours after hospital admission, while in bed and not receiving nasogastric feeding.
Management of atrial fibrillation (Chapter 4) 22/12/2021 Closing off the opening to the left atrial appendage may be reasonable when long-term anticoagulation is not possible.
Lifestyle modifications (Chapter 4) 22/12/2021 Everyone who has had a stroke or TIA may be given interventions addressing secondary stroke risk factors, with support and counselling, reviews by health care professionals, and exercise training. Also, a new consensus recommendation for a Mediterranean or similar style diet, and referral to a dietitian for individualised advice.
Arm activity (Chapter 5) 22/12/2021 Virtual reality and interactive games may now be used with any timing and duration, and independently of impairment severity.
Memory (Chapter 5) 22/12/2021 Cognitive rehabilitation, including both internal strategies and external aids, may be used to improve memory function in the short term.
Telehealth in rehabilitation (Chapter 5) 22/12/2021 New topic with recommendation that telehealth services may be used as an adjunct to in-person therapy, or an alternative for patients who cannot access specialist rehab in the community.
Swelling of the extremities (Chapter 6) 22/12/2021 Passive mobilisation is now recommended for prevention and management, along with elevation of the limb when resting.
Antiplatelet therapy (Chapter 4) 7/07/2021 Restarting antiplatelet therapy can be considered after the acute phase of an intracerebral haemorrhage if the person was previously on antithrombotic therapy.
Standing (Chapter 5) 7/07/2021 Recommendation for task-specific practice now split into a strong recommendation for activities that challenge balance, plus a weak recommendation for adding on virtual reality training, visual or auditory feedback or electromechanical assistance.
Activities of daily living (Chapter 5) 7/07/2021 Updated from strong recommendation against to a weak recommendation against routinely using acupuncture to improve activities of daily living. In addition, a new weak recommendation against using selective serotonin reuptake inhibitors to reduce disability.
Fatigue (Chapter 6) 7/07/2021 Minor wording changes and a mention of cognitive behavioural therapy as a possible intervention.
Sexuality (Chapter 8) 7/07/2021 New evidence added, but no change in recommendation apart from minor wording changes.
Acute antiplatelet therapy (Chapter 3) 11/02/2021 A new drug, ticagrelor, in combination with aspirin soon after a minor ischaemic stroke or high-risk transient ischaemic attack, may be considered to prevent another stroke.
Oxygen therapy (Chapter 3) 11/02/2021 More specific targets and thresholds set for blood oxygen levels, above which supplemental oxygen should not be given.
Cholesterol lowering therapy (Chapter 4) 11/02/2021 A new target set for lowering LDL cholesterol to prevent further strokes and cardiovascular disease.
Weakness (Chapter 5) 11/02/2021 Added new evidence for recovery of muscle strength with progressive resistance training. Also a new recommendation for certain types of repetitive practice.
Shoulder pain (Chapter 6) 11/02/2021 Electrical stimulation may now be used for pain management, when previously it was recommended against. Acupuncture may also be used to reduce pain.
Thrombolysis (Chapter 3) 7/11/2019 Time window for intravenous thrombolysis extended up to 9 hours after a person has had their stroke, if brain scans show they will benefit. The 9 hours can be counted from the mid-point of sleep if the person woke up with stroke symptoms. Tenecteplase may also be used in thrombolysis as an alternative to alteplase, especially for people with a blockage in large brain arteries.
Acute antithrombotic therapy (Chapter 3) 7/11/2019 Upgrade to strong recommendation for taking the antiplatelet medications aspirin and clopidogrel together in the first three weeks after a minor stroke or transient ischaemic attack (TIA).
Patent foramen ovale (PFO) management (Chapter 4) 7/11/2019 Closing a PFO (patent foramen ovale) is recommended when people under 60 years old have had a stroke, and other possible causes of their stroke have been ruled out.

See all current recommendations in the Clinical Guidelines for Stroke Management.


Changes to background evidence or text including practical information

Minor changes have been made to a number of topics. These are summarised below and can be found in the Clinical Guidelines for Stroke Management.

Topic Date Comment
Urinary incontinence (Chapter 6) 5/11/2021 Added new evidence for urge incontinence, and decision aid for specialised professional input.
Carer training (Chapter 7) 1/07/2021 Added practical info.
Walking (Chapter 5) 10/06/2021 Updated evidence and added decision aids.
Surgery for ischaemic stroke (Chapter 3) 8/06/2021 Updated evidence for recommendations about decompressive hemicraniectomy.
Cerebral venous sinus thrombosis (Chapter 4) 25/05/2021 Added practical info with advice related to COVID-19 vaccines.
Oral hygiene (Chapter 6) 13/05/2021 Updated evidence and practical info.
Subluxation (Chapter 6) 13/05/2021 Added new evidence and decision aids for consensus-based recommendation on use of supports and slings.
Pre-hospital care (Chapter 1) 5/05/2021 Updated evidence for recommendation about ambulance services transferring suspected stroke patients and pre-notifying hospital.
Arm activity (Chapter 5) 17/03/2021 Updated evidence, moved information on trunk restraint during therapy to practical info of strong recommendation for constraint-induced movement therapy.
Visual field loss (Chapter 5) 17/03/2021 Added practical info about screening of visual function and daily living with visual field loss post stroke.
Standing balance (Chapter 5) 17/03/2021 Updated practical info for virtual reality recommendation, and added decision aids.
Activities of daily living (Chapter 5) 17/03/2021 Added new evidence, updated and added practical info for several recommendations.
Perception (Chapter 5) 17/03/2021 Added practical info about assessing perceptual difficulties.
Attention and concentration (Chapter 5) 17/03/2021 Added and updated evidence.
Executive function (Chapter 5) 17/03/2021 Added new evidence and updated practical info.
Neglect (Chapter 5) 17/03/2021 Updated evidence and practical info.
Antiplatelet therapy (Chapter 4) 16/03/2021 Updated evidence, included new brand names in practical info, and added decision aids.
Carotid surgery (Chapter 4) 16/03/2021 Updated evidence, added and updated practical info for all recommendations, to describe optimal medical management.
Contracture (Chapter 6) 16/03/2021 Minor wording change and updated evidence, rationale and practical info for recommendation against routine use of splints and stretch.
Subluxation (Chapter 6) 16/03/2021 Added new evidence to recommendation for electrical stimulation.
Faecal incontinence (Chapter 6) 16/03/2021 Practical info added, including link to recommendations from Continence Foundation of Australia, and an assessment and treatment protocol flowchart
Prevention of depression (Chapter 6) 16/03/2021 Updated evidence, removed decision aid for psychotherapy.
Deep venous thrombosis or pulmonary embolism (Chapter 6) 16/03/2021 Added evidence and decision aids to practice points.
Pre-hospital care (Chapter 1) 12/02/2021 Added new reference to resources considerations under evidence to decision, and to practical info.
Thrombolysis (Chapter 3) 12/02/2021 Updated eligibility criteria under practical info for intravenous thrombolysis within 4.5 hours of stroke onset.
Information and education (Chapter 7) 12/02/2021 Added new evidence.
Home assessment (Chapter 7) 12/02/2021 Added practical info about assistive technology for safe discharge and OT home visits.
Self-management (Chapter 8) 12/02/2021 Added new evidence.
Leisure (Chapter 8) 12/02/2021 Replaced decision aid with practical info.
Return to work (Chapter 8) 12/02/2021 Added new evidence.
Sexuality (Chapter 8) 12/02/2021 Added background evidence, practical info and decision aids.
Peer support (Chapter 8) 12/02/2021 Updated evidence and rationale, replaced decision aid with practical info.
Commencement of rehabilitation (Chapter 5) (formerly Early mobilisation) 11/09/2020 Added new evidence.
Goal setting (Chapter 5) 11/09/2020 Added new reference to resources considerations under evidence to decision.
Limb apraxia (Chapter 5) 11/09/2020 Added practical info to practice point on screening for apraxia.
Spasticity (Chapter 6) 11/09/2020 Updated background evidence in weak recommendation against use of stretch.
Shoulder pain (Chapter 6) 11/09/2020 Added new background evidence for shoulder strapping.
Treatment for emotionalism (Chapter 6) (formerly Treatment for emotional distress) 11/09/2020 Updated background evidence.
Treatment for depression (Chapter 6) 11/09/2020 Updated background evidence and added decision aids.
Falls (Chapter 6) 11/09/2020 Updated background evidence and practical info.
Management of atrial fibrillation (Chapter 4) (formerly Anticoagulant therapy) 8/09/2020 Updated background evidence and practical info for use of oral anticoagulation. 
Information and education (Chapter 7) 3/09/2020 Updated practical info.
Discharge care plans (Chapter 7) 3/09/2020 Added practical info to strong recommendation for comprehensive discharge care plans, and expanded practical info on consensus-based recommendation for discharge care planner coordination.
Self-management (Chapter 8) 3/09/2020 Added practical info.
Driving (Chapter 8) 3/09/2020 Expanded practical info.
Community mobility and outdoor travel (Chapter 8) 3/09/2020 Expanded practical info.
Leisure (Chapter 8) 3/09/2020 Added new evidence, and decision aid for leisure therapy.
Return to work (Chapter 8) 3/09/2020 Expanded practical info.
Peer support (Chapter 8) 3/09/2020 Added new evidence and decision aid.
Carer support (Chapter 8) 3/09/2020 Added decision aid for support and information.
Pre-hospital care (Chapter 1) 1/09/2020 Updated practical info for interventions by paramedics.
Cholesterol lowering therapy (Chapter 4) 10/06/2020 Updated practical info for use of statins after ischaemic stroke or TIA.
Cervical artery dissection (Chapter 4) 10/06/2020 Added outcomes of new reference to evidence summary, and benefits and harms under evidence to decision.
Hormone replacement therapy (Chapter 4) 10/06/2020 Added new reference to benefits and harms under evidence to decision.
Oral contraception (Chapter 4) 10/06/2020 Updated rationale and practical info for weak recommendation about oral contraception after stroke.


Suggest a new topic or question

To keep our living guidelines relevant, we annually review the topics the guidelines cover and the questions about practice that they answer. The current topics make up the table of contents of the Clinical Guidelines.

We welcome your suggestions for new topics that you believe are critical to include. New topics will be considered during our project steering committee's annual review.

Please email your suggestions to guidelines@strokefoundation.org.au